|
K-WIRE WITH OLIVE 1.2MM X 65MM TROCAR TIP SMOOTH XBR001002
|
Facility
|
OP
|
$2,527.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5547409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$707.56 |
| Max. Negotiated Rate |
$10,108.00 |
| Rate for Payer: Aetna Commercial |
$2,274.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,173.22
|
| Rate for Payer: Aetna Managed Medicare |
$707.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,642.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,263.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,212.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,339.31
|
| Rate for Payer: Cash Price |
$758.10
|
| Rate for Payer: Cigna Commercial |
$2,324.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,414.11
|
| Rate for Payer: Health EOS Commercial |
$2,249.03
|
| Rate for Payer: HFN Commercial |
$2,324.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,895.25
|
| Rate for Payer: Multiplan Commercial |
$2,021.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,516.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,324.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,238.23
|
| Rate for Payer: Quartz Commercial |
$1,642.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,516.20
|
| Rate for Payer: The Alliance Commercial |
$10,108.00
|
| Rate for Payer: WEA Trust Commercial |
$1,389.85
|
| Rate for Payer: WPS Commercial |
$1,871.75
|
|
|
K-WIRE WITH OLIVE 1.2MM X 65MM TROCAR TIP SMOOTH XBR001002
|
Facility
|
IP
|
$2,527.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5547409
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,238.23 |
| Max. Negotiated Rate |
$2,324.84 |
| Rate for Payer: Aetna Commercial |
$2,274.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,173.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,339.31
|
| Rate for Payer: Cash Price |
$758.10
|
| Rate for Payer: Cigna Commercial |
$2,324.84
|
| Rate for Payer: Health EOS Commercial |
$2,249.03
|
| Rate for Payer: HFN Commercial |
$2,324.84
|
| Rate for Payer: Multiplan Commercial |
$2,021.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,516.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,324.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,238.23
|
| Rate for Payer: Quartz Commercial |
$1,516.20
|
| Rate for Payer: WEA Trust Commercial |
$1,389.85
|
| Rate for Payer: WPS Commercial |
$1,871.75
|
|
|
Kyleena 1 unit Charge
|
Facility
|
OP
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$674.52 |
| Max. Negotiated Rate |
$9,636.00 |
| Rate for Payer: Aetna Commercial |
$2,168.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,071.74
|
| Rate for Payer: Aetna Managed Medicare |
$674.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,565.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,204.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,156.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,276.77
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,216.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,348.08
|
| Rate for Payer: Health EOS Commercial |
$2,144.01
|
| Rate for Payer: HFN Commercial |
$2,216.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,806.75
|
| Rate for Payer: Multiplan Commercial |
$1,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,445.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,216.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,180.41
|
| Rate for Payer: Quartz Commercial |
$1,565.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,445.40
|
| Rate for Payer: The Alliance Commercial |
$9,636.00
|
| Rate for Payer: WEA Trust Commercial |
$1,324.95
|
| Rate for Payer: WPS Commercial |
$1,784.35
|
|
|
Kyleena 1 unit Charge
|
Professional
|
Both
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$999.28 |
| Max. Negotiated Rate |
$2,288.55 |
| Rate for Payer: Aetna Commercial |
$2,288.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,071.74
|
| Rate for Payer: Anthem Commercial |
$999.28
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,288.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,156.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,445.40
|
| Rate for Payer: Health EOS Commercial |
$2,192.19
|
| Rate for Payer: HFN Commercial |
$2,288.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,488.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,488.13
|
| Rate for Payer: Multiplan Commercial |
$1,927.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,288.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.96
|
| Rate for Payer: Quartz Commercial |
$1,373.13
|
| Rate for Payer: The Alliance Commercial |
$1,204.50
|
| Rate for Payer: United Healthcare Medicaid |
$1,156.79
|
| Rate for Payer: WEA Trust Commercial |
$1,324.95
|
| Rate for Payer: WPS Commercial |
$1,784.35
|
|
|
Kyleena 1 unit Charge
|
Facility
|
IP
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,180.41 |
| Max. Negotiated Rate |
$2,216.28 |
| Rate for Payer: Aetna Commercial |
$2,168.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,071.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,276.77
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,216.28
|
| Rate for Payer: Health EOS Commercial |
$2,144.01
|
| Rate for Payer: HFN Commercial |
$2,216.28
|
| Rate for Payer: Multiplan Commercial |
$1,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,445.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,216.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,180.41
|
| Rate for Payer: Quartz Commercial |
$1,445.40
|
| Rate for Payer: WEA Trust Commercial |
$1,324.95
|
| Rate for Payer: WPS Commercial |
$1,784.35
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
OP
|
$2,330.00
|
|
| Hospital Charge Code |
6180102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$652.40 |
| Max. Negotiated Rate |
$9,320.00 |
| Rate for Payer: Aetna Commercial |
$2,097.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,003.80
|
| Rate for Payer: Aetna Managed Medicare |
$652.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,514.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,165.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,118.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,234.90
|
| Rate for Payer: Cash Price |
$699.00
|
| Rate for Payer: Cigna Commercial |
$2,143.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,303.87
|
| Rate for Payer: Health EOS Commercial |
$2,073.70
|
| Rate for Payer: HFN Commercial |
$2,143.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,747.50
|
| Rate for Payer: Multiplan Commercial |
$1,864.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,398.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,143.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,141.70
|
| Rate for Payer: Quartz Commercial |
$1,514.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,398.00
|
| Rate for Payer: The Alliance Commercial |
$9,320.00
|
| Rate for Payer: WEA Trust Commercial |
$1,281.50
|
| Rate for Payer: WPS Commercial |
$1,725.83
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
IP
|
$2,330.00
|
|
| Hospital Charge Code |
6180102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,141.70 |
| Max. Negotiated Rate |
$2,143.60 |
| Rate for Payer: Aetna Commercial |
$2,097.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,003.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,234.90
|
| Rate for Payer: Cash Price |
$699.00
|
| Rate for Payer: Cigna Commercial |
$2,143.60
|
| Rate for Payer: Health EOS Commercial |
$2,073.70
|
| Rate for Payer: HFN Commercial |
$2,143.60
|
| Rate for Payer: Multiplan Commercial |
$1,864.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,398.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,143.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,141.70
|
| Rate for Payer: Quartz Commercial |
$1,398.00
|
| Rate for Payer: WEA Trust Commercial |
$1,281.50
|
| Rate for Payer: WPS Commercial |
$1,725.83
|
|
|
KYPHOPLASTY LUMBAR ADD LEVEL
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
6180100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$624.26 |
| Max. Negotiated Rate |
$1,172.08 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$764.40
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
KYPHOPLASTY LUMBAR ADD LEVEL
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
6180100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$5,096.00 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Aetna Managed Medicare |
$356.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$828.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$611.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$712.93
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$955.50
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$828.10
|
| Rate for Payer: Quartz Medicare Advantage |
$764.40
|
| Rate for Payer: The Alliance Commercial |
$5,096.00
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
OP
|
$2,540.00
|
|
| Hospital Charge Code |
6180103
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$711.20 |
| Max. Negotiated Rate |
$10,160.00 |
| Rate for Payer: Aetna Commercial |
$2,286.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,184.40
|
| Rate for Payer: Aetna Managed Medicare |
$711.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,651.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,270.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,219.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,346.20
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$2,336.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,421.38
|
| Rate for Payer: Health EOS Commercial |
$2,260.60
|
| Rate for Payer: HFN Commercial |
$2,336.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,905.00
|
| Rate for Payer: Multiplan Commercial |
$2,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,524.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,336.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,244.60
|
| Rate for Payer: Quartz Commercial |
$1,651.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,524.00
|
| Rate for Payer: The Alliance Commercial |
$10,160.00
|
| Rate for Payer: WEA Trust Commercial |
$1,397.00
|
| Rate for Payer: WPS Commercial |
$1,881.38
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
IP
|
$2,540.00
|
|
| Hospital Charge Code |
6180103
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,244.60 |
| Max. Negotiated Rate |
$2,336.80 |
| Rate for Payer: Aetna Commercial |
$2,286.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,184.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,346.20
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$2,336.80
|
| Rate for Payer: Health EOS Commercial |
$2,260.60
|
| Rate for Payer: HFN Commercial |
$2,336.80
|
| Rate for Payer: Multiplan Commercial |
$2,032.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,524.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,336.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,244.60
|
| Rate for Payer: Quartz Commercial |
$1,524.00
|
| Rate for Payer: WEA Trust Commercial |
$1,397.00
|
| Rate for Payer: WPS Commercial |
$1,881.38
|
|
|
KYPHOPLASTY THORACIC ADD LEVEL
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
6180101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$624.26 |
| Max. Negotiated Rate |
$1,172.08 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$764.40
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
KYPHOPLASTY THORACIC ADD LEVEL
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
6180101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$5,096.00 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Aetna Managed Medicare |
$356.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$828.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$611.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$712.93
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$955.50
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$828.10
|
| Rate for Payer: Quartz Medicare Advantage |
$764.40
|
| Rate for Payer: The Alliance Commercial |
$5,096.00
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
LABELS AND MARKER STERILE 3334-P
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2962812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
LABELS AND MARKER STERILE 3334-P
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2962812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
LABRALTAPE 1.5MM WHITE/BLACK AR-7276T
|
Facility
|
OP
|
$1,230.00
|
|
| Hospital Charge Code |
5107166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$344.40 |
| Max. Negotiated Rate |
$4,920.00 |
| Rate for Payer: Aetna Commercial |
$1,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,057.80
|
| Rate for Payer: Aetna Managed Medicare |
$344.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$799.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$615.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$590.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$651.90
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$1,131.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$688.31
|
| Rate for Payer: Health EOS Commercial |
$1,094.70
|
| Rate for Payer: HFN Commercial |
$1,131.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$922.50
|
| Rate for Payer: Multiplan Commercial |
$984.00
|
| Rate for Payer: NAPHCARE Commercial |
$738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,131.60
|
| Rate for Payer: Quartz Beloit One Network |
$602.70
|
| Rate for Payer: Quartz Commercial |
$799.50
|
| Rate for Payer: Quartz Medicare Advantage |
$738.00
|
| Rate for Payer: The Alliance Commercial |
$4,920.00
|
| Rate for Payer: WEA Trust Commercial |
$676.50
|
| Rate for Payer: WPS Commercial |
$911.06
|
|
|
LABRALTAPE 1.5MM WHITE/BLACK AR-7276T
|
Facility
|
IP
|
$1,230.00
|
|
| Hospital Charge Code |
5107166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$602.70 |
| Max. Negotiated Rate |
$1,131.60 |
| Rate for Payer: Aetna Commercial |
$1,107.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,057.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$651.90
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$1,131.60
|
| Rate for Payer: Health EOS Commercial |
$1,094.70
|
| Rate for Payer: HFN Commercial |
$1,131.60
|
| Rate for Payer: Multiplan Commercial |
$984.00
|
| Rate for Payer: NAPHCARE Commercial |
$738.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,131.60
|
| Rate for Payer: Quartz Beloit One Network |
$602.70
|
| Rate for Payer: Quartz Commercial |
$738.00
|
| Rate for Payer: WEA Trust Commercial |
$676.50
|
| Rate for Payer: WPS Commercial |
$911.06
|
|
|
LABYRINTHECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960165
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
LABYRINTHECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960165
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
Lacosamide
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$106.72 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$106.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.91
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$103.24
|
| Rate for Payer: HFN Commercial |
$106.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$106.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$56.84
|
| Rate for Payer: Quartz Commercial |
$75.40
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
Lacosamide
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$110.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.60
|
| Rate for Payer: Health EOS Commercial |
$105.56
|
| Rate for Payer: HFN Commercial |
$110.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: Preferred Network Access Commercial |
$110.20
|
| Rate for Payer: Quartz Beloit One Network |
$51.04
|
| Rate for Payer: Quartz Commercial |
$66.12
|
| Rate for Payer: The Alliance Commercial |
$58.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
Lacosamide
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.84 |
| Max. Negotiated Rate |
$106.72 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.48
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$106.72
|
| Rate for Payer: Health EOS Commercial |
$103.24
|
| Rate for Payer: HFN Commercial |
$106.72
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$69.60
|
| Rate for Payer: Preferred Network Access Commercial |
$106.72
|
| Rate for Payer: Quartz Beloit One Network |
$56.84
|
| Rate for Payer: Quartz Commercial |
$69.60
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
Lacrimal Closure by plug, each
|
Professional
|
Both
|
$403.00
|
|
|
Service Code
|
CPT 68761
|
| Hospital Charge Code |
1188912
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$397.41 |
| Rate for Payer: Aetna Commercial |
$382.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$346.58
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Cash Price |
$120.90
|
| Rate for Payer: Cigna Commercial |
$382.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.80
|
| Rate for Payer: Health EOS Commercial |
$366.73
|
| Rate for Payer: HFN Commercial |
$382.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$397.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$397.41
|
| Rate for Payer: Multiplan Commercial |
$322.40
|
| Rate for Payer: Preferred Network Access Commercial |
$382.85
|
| Rate for Payer: Quartz Beloit One Network |
$177.32
|
| Rate for Payer: Quartz Commercial |
$229.71
|
| Rate for Payer: The Alliance Commercial |
$201.50
|
| Rate for Payer: United Healthcare Medicaid |
$95.46
|
| Rate for Payer: WEA Trust Commercial |
$221.65
|
| Rate for Payer: WPS Commercial |
$298.50
|
|
|
Lacrimal Closure by plug, each 6876150
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
CPT 68761
|
| Hospital Charge Code |
5174607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$767.60 |
| Rate for Payer: Aetna Commercial |
$767.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$694.88
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cigna Commercial |
$767.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.80
|
| Rate for Payer: Health EOS Commercial |
$735.28
|
| Rate for Payer: HFN Commercial |
$767.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$397.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$397.41
|
| Rate for Payer: Multiplan Commercial |
$646.40
|
| Rate for Payer: Preferred Network Access Commercial |
$767.60
|
| Rate for Payer: Quartz Beloit One Network |
$355.52
|
| Rate for Payer: Quartz Commercial |
$460.56
|
| Rate for Payer: The Alliance Commercial |
$404.00
|
| Rate for Payer: United Healthcare Medicaid |
$95.46
|
| Rate for Payer: WEA Trust Commercial |
$444.40
|
| Rate for Payer: WPS Commercial |
$598.49
|
|
|
LACRIMAL DUCT, IRRIGATION/PROBING/LACERATION
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960167
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
