|
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
|
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 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 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.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.75 2652234"
|
Facility
|
IP
|
$279.00
|
|
| Hospital Charge Code |
4508807
|
|
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.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
|
|
|
KIT PRO-TOE VO DISP 4571-0500
|
Facility
|
IP
|
$3,172.00
|
|
| Hospital Charge Code |
3072447
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,616.45 |
| Max. Negotiated Rate |
$3,034.97 |
| Rate for Payer: Aetna Commercial |
$2,968.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,837.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,748.41
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,034.97
|
| Rate for Payer: Health EOS Commercial |
$2,936.00
|
| Rate for Payer: HFN Commercial |
$3,034.97
|
| Rate for Payer: Multiplan Commercial |
$2,639.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,616.45
|
| Rate for Payer: Quartz Commercial |
$1,979.33
|
| Rate for Payer: WEA Trust Commercial |
$1,814.38
|
| Rate for Payer: WPS Commercial |
$2,443.39
|
|
|
KIT PRO-TOE VO DISP 4571-0500
|
Facility
|
OP
|
$3,172.00
|
|
| Hospital Charge Code |
3072447
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$923.69 |
| Max. Negotiated Rate |
$3,034.97 |
| Rate for Payer: Aetna Commercial |
$2,968.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,837.04
|
| Rate for Payer: Aetna Managed Medicare |
$923.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,144.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,649.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,583.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,748.41
|
| Rate for Payer: Cash Price |
$951.60
|
| Rate for Payer: Cigna Commercial |
$3,034.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,846.10
|
| Rate for Payer: Health EOS Commercial |
$2,936.00
|
| Rate for Payer: HFN Commercial |
$3,034.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,474.16
|
| Rate for Payer: Multiplan Commercial |
$2,639.10
|
| Rate for Payer: NAPHCARE Commercial |
$1,979.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,616.45
|
| Rate for Payer: Quartz Commercial |
$2,144.27
|
| Rate for Payer: Quartz Medicare Advantage |
$1,979.33
|
| Rate for Payer: The Alliance Commercial |
$1,649.44
|
| Rate for Payer: WEA Trust Commercial |
$1,814.38
|
| Rate for Payer: WPS Commercial |
$2,443.39
|
|
|
KIT QUADRIPOLAR LEAD INTERSTIM 3889-28
|
Facility
|
OP
|
$21,647.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
5349492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,303.61 |
| Max. Negotiated Rate |
$20,711.85 |
| Rate for Payer: Aetna Commercial |
$20,261.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,361.08
|
| Rate for Payer: Aetna Managed Medicare |
$6,303.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,633.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,256.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,806.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,931.83
|
| Rate for Payer: Cash Price |
$6,494.10
|
| Rate for Payer: Cigna Commercial |
$20,711.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,598.55
|
| Rate for Payer: Health EOS Commercial |
$20,036.46
|
| Rate for Payer: HFN Commercial |
$20,711.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,884.66
|
| Rate for Payer: Multiplan Commercial |
$18,010.30
|
| Rate for Payer: NAPHCARE Commercial |
$13,507.73
|
| Rate for Payer: Preferred Network Access Commercial |
$20,711.85
|
| Rate for Payer: Quartz Beloit One Network |
$11,031.31
|
| Rate for Payer: Quartz Commercial |
$14,633.37
|
| Rate for Payer: Quartz Medicare Advantage |
$13,507.73
|
| Rate for Payer: The Alliance Commercial |
$11,256.44
|
| Rate for Payer: WEA Trust Commercial |
$12,382.08
|
| Rate for Payer: WPS Commercial |
$16,674.68
|
|
|
KIT QUADRIPOLAR LEAD INTERSTIM 3889-28
|
Facility
|
IP
|
$21,647.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
5349492
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,031.31 |
| Max. Negotiated Rate |
$20,711.85 |
| Rate for Payer: Aetna Commercial |
$20,261.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,361.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,931.83
|
| Rate for Payer: Cash Price |
$6,494.10
|
| Rate for Payer: Cigna Commercial |
$20,711.85
|
| Rate for Payer: Health EOS Commercial |
$20,036.46
|
| Rate for Payer: HFN Commercial |
$20,711.85
|
| Rate for Payer: Multiplan Commercial |
$18,010.30
|
| Rate for Payer: Preferred Network Access Commercial |
$20,711.85
|
| Rate for Payer: Quartz Beloit One Network |
$11,031.31
|
| Rate for Payer: Quartz Commercial |
$13,507.73
|
| Rate for Payer: WEA Trust Commercial |
$12,382.08
|
| Rate for Payer: WPS Commercial |
$16,674.68
|
|
|
KIT QUICKSET ARTHREX INJECTABLE MACROPOROUS CALCIUM PHOSPHATE 5CC ABS-3005
|
Facility
|
IP
|
$12,637.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5521095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,439.82 |
| Max. Negotiated Rate |
$12,091.08 |
| Rate for Payer: Aetna Commercial |
$11,828.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,302.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,965.51
|
| Rate for Payer: Cash Price |
$3,791.10
|
| Rate for Payer: Cigna Commercial |
$12,091.08
|
| Rate for Payer: Health EOS Commercial |
$11,696.81
|
| Rate for Payer: HFN Commercial |
$12,091.08
|
| Rate for Payer: Multiplan Commercial |
$10,513.98
|
| Rate for Payer: Preferred Network Access Commercial |
$12,091.08
|
| Rate for Payer: Quartz Beloit One Network |
$6,439.82
|
| Rate for Payer: Quartz Commercial |
$7,885.49
|
| Rate for Payer: WEA Trust Commercial |
$7,228.36
|
| Rate for Payer: WPS Commercial |
$9,734.28
|
|
|
KIT QUICKSET ARTHREX INJECTABLE MACROPOROUS CALCIUM PHOSPHATE 5CC ABS-3005
|
Facility
|
OP
|
$12,637.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5521095
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,679.89 |
| Max. Negotiated Rate |
$12,091.08 |
| Rate for Payer: Aetna Commercial |
$11,828.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,302.53
|
| Rate for Payer: Aetna Managed Medicare |
$3,679.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,542.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,571.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,308.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,965.51
|
| Rate for Payer: Cash Price |
$3,791.10
|
| Rate for Payer: Cigna Commercial |
$12,091.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,354.73
|
| Rate for Payer: Health EOS Commercial |
$11,696.81
|
| Rate for Payer: HFN Commercial |
$12,091.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,856.86
|
| Rate for Payer: Multiplan Commercial |
$10,513.98
|
| Rate for Payer: NAPHCARE Commercial |
$7,885.49
|
| Rate for Payer: Preferred Network Access Commercial |
$12,091.08
|
| Rate for Payer: Quartz Beloit One Network |
$6,439.82
|
| Rate for Payer: Quartz Commercial |
$8,542.61
|
| Rate for Payer: Quartz Medicare Advantage |
$7,885.49
|
| Rate for Payer: The Alliance Commercial |
$6,571.24
|
| Rate for Payer: WEA Trust Commercial |
$7,228.36
|
| Rate for Payer: WPS Commercial |
$9,734.28
|
|
|
KIT RECHARGER INTERSTIM WIRELESS RS5200
|
Facility
|
IP
|
$7,181.00
|
|
| Hospital Charge Code |
5603555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,659.44 |
| Max. Negotiated Rate |
$6,870.78 |
| Rate for Payer: Aetna Commercial |
$6,721.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,422.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.17
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,870.78
|
| Rate for Payer: Health EOS Commercial |
$6,646.73
|
| Rate for Payer: HFN Commercial |
$6,870.78
|
| Rate for Payer: Multiplan Commercial |
$5,974.59
|
| Rate for Payer: Preferred Network Access Commercial |
$6,870.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.44
|
| Rate for Payer: Quartz Commercial |
$4,480.94
|
| Rate for Payer: WEA Trust Commercial |
$4,107.53
|
| Rate for Payer: WPS Commercial |
$5,531.52
|
|
|
KIT RECHARGER INTERSTIM WIRELESS RS5200
|
Facility
|
OP
|
$7,181.00
|
|
| Hospital Charge Code |
5603555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,091.11 |
| Max. Negotiated Rate |
$6,870.78 |
| Rate for Payer: Aetna Commercial |
$6,721.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,422.69
|
| Rate for Payer: Aetna Managed Medicare |
$2,091.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,854.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,734.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,584.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.17
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,870.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,179.34
|
| Rate for Payer: Health EOS Commercial |
$6,646.73
|
| Rate for Payer: HFN Commercial |
$6,870.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,601.18
|
| Rate for Payer: Multiplan Commercial |
$5,974.59
|
| Rate for Payer: NAPHCARE Commercial |
$4,480.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,870.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.44
|
| Rate for Payer: Quartz Commercial |
$4,854.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4,480.94
|
| Rate for Payer: The Alliance Commercial |
$3,734.12
|
| Rate for Payer: WEA Trust Commercial |
$4,107.53
|
| Rate for Payer: WPS Commercial |
$5,531.52
|
|
|
KIT REPAIR CATHETER 5587000
|
Facility
|
IP
|
$4,610.00
|
|
| Hospital Charge Code |
3098295
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,349.26 |
| Max. Negotiated Rate |
$4,410.85 |
| Rate for Payer: Aetna Commercial |
$4,314.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,123.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,541.03
|
| Rate for Payer: Cash Price |
$1,383.00
|
| Rate for Payer: Cigna Commercial |
$4,410.85
|
| Rate for Payer: Health EOS Commercial |
$4,267.02
|
| Rate for Payer: HFN Commercial |
$4,410.85
|
| Rate for Payer: Multiplan Commercial |
$3,835.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,410.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,349.26
|
| Rate for Payer: Quartz Commercial |
$2,876.64
|
| Rate for Payer: WEA Trust Commercial |
$2,636.92
|
| Rate for Payer: WPS Commercial |
$3,551.08
|
|
|
KIT REPAIR CATHETER 5587000
|
Facility
|
OP
|
$4,610.00
|
|
| Hospital Charge Code |
3098295
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,342.43 |
| Max. Negotiated Rate |
$4,410.85 |
| Rate for Payer: Aetna Commercial |
$4,314.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,123.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,342.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,116.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,397.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,301.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,541.03
|
| Rate for Payer: Cash Price |
$1,383.00
|
| Rate for Payer: Cigna Commercial |
$4,410.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,683.02
|
| Rate for Payer: Health EOS Commercial |
$4,267.02
|
| Rate for Payer: HFN Commercial |
$4,410.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,595.80
|
| Rate for Payer: Multiplan Commercial |
$3,835.52
|
| Rate for Payer: NAPHCARE Commercial |
$2,876.64
|
| Rate for Payer: Preferred Network Access Commercial |
$4,410.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,349.26
|
| Rate for Payer: Quartz Commercial |
$3,116.36
|
| Rate for Payer: Quartz Medicare Advantage |
$2,876.64
|
| Rate for Payer: The Alliance Commercial |
$2,397.20
|
| Rate for Payer: WEA Trust Commercial |
$2,636.92
|
| Rate for Payer: WPS Commercial |
$3,551.08
|
|
|
KIT RESUS ADJ MSK42 10 #RD1340-10
|
Facility
|
OP
|
$293.00
|
|
| Hospital Charge Code |
2972716
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$85.32 |
| Max. Negotiated Rate |
$280.34 |
| Rate for Payer: Aetna Commercial |
$274.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.06
|
| Rate for Payer: Aetna Managed Medicare |
$85.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$198.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$152.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$146.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.50
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$280.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.53
|
| Rate for Payer: Health EOS Commercial |
$271.20
|
| Rate for Payer: HFN Commercial |
$280.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.54
|
| Rate for Payer: Multiplan Commercial |
$243.78
|
| Rate for Payer: NAPHCARE Commercial |
$182.83
|
| Rate for Payer: Preferred Network Access Commercial |
$280.34
|
| Rate for Payer: Quartz Beloit One Network |
$149.31
|
| Rate for Payer: Quartz Commercial |
$198.07
|
| Rate for Payer: Quartz Medicare Advantage |
$182.83
|
| Rate for Payer: The Alliance Commercial |
$152.36
|
| Rate for Payer: WEA Trust Commercial |
$167.60
|
| Rate for Payer: WPS Commercial |
$225.70
|
|
|
KIT RESUS ADJ MSK42 10 #RD1340-10
|
Facility
|
IP
|
$293.00
|
|
| Hospital Charge Code |
2972716
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$149.31 |
| Max. Negotiated Rate |
$280.34 |
| Rate for Payer: Aetna Commercial |
$274.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.50
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$280.34
|
| Rate for Payer: Health EOS Commercial |
$271.20
|
| Rate for Payer: HFN Commercial |
$280.34
|
| Rate for Payer: Multiplan Commercial |
$243.78
|
| Rate for Payer: Preferred Network Access Commercial |
$280.34
|
| Rate for Payer: Quartz Beloit One Network |
$149.31
|
| Rate for Payer: Quartz Commercial |
$182.83
|
| Rate for Payer: WEA Trust Commercial |
$167.60
|
| Rate for Payer: WPS Commercial |
$225.70
|
|
|
KIT RESUS ADJ MSK50 10 #RD1350-10
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2972426
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
