|
KNIFE MICROSURGICAL BAYONET
|
Facility
|
OP
|
$1,281.00
|
|
| Hospital Charge Code |
2965956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$373.03 |
| Max. Negotiated Rate |
$1,225.66 |
| Rate for Payer: Aetna Commercial |
$1,199.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.73
|
| Rate for Payer: Aetna Managed Medicare |
$373.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$865.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$666.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$639.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$706.09
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,225.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$745.54
|
| Rate for Payer: Health EOS Commercial |
$1,185.69
|
| Rate for Payer: HFN Commercial |
$1,225.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$999.18
|
| Rate for Payer: Multiplan Commercial |
$1,065.79
|
| Rate for Payer: NAPHCARE Commercial |
$799.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.66
|
| Rate for Payer: Quartz Beloit One Network |
$652.80
|
| Rate for Payer: Quartz Commercial |
$865.96
|
| Rate for Payer: Quartz Medicare Advantage |
$799.34
|
| Rate for Payer: The Alliance Commercial |
$666.12
|
| Rate for Payer: WEA Trust Commercial |
$732.73
|
| Rate for Payer: WPS Commercial |
$986.75
|
|
|
KNIFE MICROSURGICAL STRAIGHT
|
Facility
|
IP
|
$1,281.00
|
|
| Hospital Charge Code |
2965957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$652.80 |
| Max. Negotiated Rate |
$1,225.66 |
| Rate for Payer: Aetna Commercial |
$1,199.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$706.09
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,225.66
|
| Rate for Payer: Health EOS Commercial |
$1,185.69
|
| Rate for Payer: HFN Commercial |
$1,225.66
|
| Rate for Payer: Multiplan Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.66
|
| Rate for Payer: Quartz Beloit One Network |
$652.80
|
| Rate for Payer: Quartz Commercial |
$799.34
|
| Rate for Payer: WEA Trust Commercial |
$732.73
|
| Rate for Payer: WPS Commercial |
$986.75
|
|
|
KNIFE MICROSURGICAL STRAIGHT
|
Facility
|
OP
|
$1,281.00
|
|
| Hospital Charge Code |
2965957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$373.03 |
| Max. Negotiated Rate |
$1,225.66 |
| Rate for Payer: Aetna Commercial |
$1,199.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.73
|
| Rate for Payer: Aetna Managed Medicare |
$373.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$865.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$666.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$639.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$706.09
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,225.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$745.54
|
| Rate for Payer: Health EOS Commercial |
$1,185.69
|
| Rate for Payer: HFN Commercial |
$1,225.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$999.18
|
| Rate for Payer: Multiplan Commercial |
$1,065.79
|
| Rate for Payer: NAPHCARE Commercial |
$799.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.66
|
| Rate for Payer: Quartz Beloit One Network |
$652.80
|
| Rate for Payer: Quartz Commercial |
$865.96
|
| Rate for Payer: Quartz Medicare Advantage |
$799.34
|
| Rate for Payer: The Alliance Commercial |
$666.12
|
| Rate for Payer: WEA Trust Commercial |
$732.73
|
| Rate for Payer: WPS Commercial |
$986.75
|
|
|
KNIFE RETRACTABLE CANNULATED STRAIGHT AR-6527-01
|
Facility
|
OP
|
$3,043.00
|
|
| Hospital Charge Code |
4509017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$886.12 |
| Max. Negotiated Rate |
$2,911.54 |
| Rate for Payer: Aetna Commercial |
$2,848.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,721.66
|
| Rate for Payer: Aetna Managed Medicare |
$886.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,057.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,582.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,519.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,677.30
|
| Rate for Payer: Cash Price |
$912.90
|
| Rate for Payer: Cigna Commercial |
$2,911.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,771.03
|
| Rate for Payer: Health EOS Commercial |
$2,816.60
|
| Rate for Payer: HFN Commercial |
$2,911.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,373.54
|
| Rate for Payer: Multiplan Commercial |
$2,531.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,898.83
|
| Rate for Payer: Preferred Network Access Commercial |
$2,911.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,550.71
|
| Rate for Payer: Quartz Commercial |
$2,057.07
|
| Rate for Payer: Quartz Medicare Advantage |
$1,898.83
|
| Rate for Payer: The Alliance Commercial |
$1,582.36
|
| Rate for Payer: WEA Trust Commercial |
$1,740.60
|
| Rate for Payer: WPS Commercial |
$2,344.02
|
|
|
KNIFE RETRACTABLE CANNULATED STRAIGHT AR-6527-01
|
Facility
|
IP
|
$3,043.00
|
|
| Hospital Charge Code |
4509017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,550.71 |
| Max. Negotiated Rate |
$2,911.54 |
| Rate for Payer: Aetna Commercial |
$2,848.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,721.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,677.30
|
| Rate for Payer: Cash Price |
$912.90
|
| Rate for Payer: Cigna Commercial |
$2,911.54
|
| Rate for Payer: Health EOS Commercial |
$2,816.60
|
| Rate for Payer: HFN Commercial |
$2,911.54
|
| Rate for Payer: Multiplan Commercial |
$2,531.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,911.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,550.71
|
| Rate for Payer: Quartz Commercial |
$1,898.83
|
| Rate for Payer: WEA Trust Commercial |
$1,740.60
|
| Rate for Payer: WPS Commercial |
$2,344.02
|
|
|
KNIFE RX NEEDLE 4584
|
Facility
|
OP
|
$2,670.00
|
|
| Hospital Charge Code |
2973085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$777.50 |
| Max. Negotiated Rate |
$2,554.66 |
| Rate for Payer: Aetna Commercial |
$2,499.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,388.05
|
| Rate for Payer: Aetna Managed Medicare |
$777.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,804.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,388.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,332.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,471.70
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$2,554.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,553.94
|
| Rate for Payer: Health EOS Commercial |
$2,471.35
|
| Rate for Payer: HFN Commercial |
$2,554.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,082.60
|
| Rate for Payer: Multiplan Commercial |
$2,221.44
|
| Rate for Payer: NAPHCARE Commercial |
$1,666.08
|
| Rate for Payer: Preferred Network Access Commercial |
$2,554.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,360.63
|
| Rate for Payer: Quartz Commercial |
$1,804.92
|
| Rate for Payer: Quartz Medicare Advantage |
$1,666.08
|
| Rate for Payer: The Alliance Commercial |
$1,388.40
|
| Rate for Payer: WEA Trust Commercial |
$1,527.24
|
| Rate for Payer: WPS Commercial |
$2,056.70
|
|
|
KNIFE RX NEEDLE 4584
|
Facility
|
IP
|
$2,670.00
|
|
| Hospital Charge Code |
2973085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,360.63 |
| Max. Negotiated Rate |
$2,554.66 |
| Rate for Payer: Aetna Commercial |
$2,499.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,388.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,471.70
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$2,554.66
|
| Rate for Payer: Health EOS Commercial |
$2,471.35
|
| Rate for Payer: HFN Commercial |
$2,554.66
|
| Rate for Payer: Multiplan Commercial |
$2,221.44
|
| Rate for Payer: Preferred Network Access Commercial |
$2,554.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,360.63
|
| Rate for Payer: Quartz Commercial |
$1,666.08
|
| Rate for Payer: WEA Trust Commercial |
$1,527.24
|
| Rate for Payer: WPS Commercial |
$2,056.70
|
|
|
KNIFE SIDEPORT CLEARCUT 1.0 8065921540
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
2964173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$281.81 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$345.07
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
KNIFE SIDEPORT CLEARCUT 1.0 8065921540
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
2964173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.03 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Aetna Managed Medicare |
$161.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.85
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$431.34
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: NAPHCARE Commercial |
$345.07
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$373.83
|
| Rate for Payer: Quartz Medicare Advantage |
$345.07
|
| Rate for Payer: The Alliance Commercial |
$287.56
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
KNIFE WITH HANDLE MYRINGOTOMY SPEAR DISP 7013-0791
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2965125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| 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: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
KNIFE WITH HANDLE MYRINGOTOMY SPEAR DISP 7013-0791
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2965125
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
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 |
$1,147.11 |
| Max. Negotiated Rate |
$2,153.76 |
| Rate for Payer: Aetna Commercial |
$2,106.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,013.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,240.75
|
| Rate for Payer: Cash Price |
$675.30
|
| Rate for Payer: Cigna Commercial |
$2,153.76
|
| Rate for Payer: Health EOS Commercial |
$2,083.53
|
| Rate for Payer: HFN Commercial |
$2,153.76
|
| Rate for Payer: Multiplan Commercial |
$1,872.83
|
| Rate for Payer: Preferred Network Access Commercial |
$2,153.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,147.11
|
| Rate for Payer: Quartz Commercial |
$1,404.62
|
| Rate for Payer: WEA Trust Commercial |
$1,287.57
|
| Rate for Payer: WPS Commercial |
$1,733.95
|
|
|
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 |
$655.49 |
| Max. Negotiated Rate |
$2,153.76 |
| Rate for Payer: Aetna Commercial |
$2,106.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,013.29
|
| Rate for Payer: Aetna Managed Medicare |
$655.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,521.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,170.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,123.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,240.75
|
| Rate for Payer: Cash Price |
$675.30
|
| Rate for Payer: Cigna Commercial |
$2,153.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,310.08
|
| Rate for Payer: Health EOS Commercial |
$2,083.53
|
| Rate for Payer: HFN Commercial |
$2,153.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,755.78
|
| Rate for Payer: Multiplan Commercial |
$1,872.83
|
| Rate for Payer: NAPHCARE Commercial |
$1,404.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,153.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,147.11
|
| Rate for Payer: Quartz Commercial |
$1,521.68
|
| Rate for Payer: Quartz Medicare Advantage |
$1,404.62
|
| Rate for Payer: The Alliance Commercial |
$1,170.52
|
| Rate for Payer: WEA Trust Commercial |
$1,287.57
|
| Rate for Payer: WPS Commercial |
$1,733.95
|
|
|
Ko elastic with joints L1810
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$121.26 |
| Max. Negotiated Rate |
$379.38 |
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Aetna Managed Medicare |
$131.58
|
| Rate for Payer: Anthem Medicare Advantage |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$131.58
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$261.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.58
|
| Rate for Payer: Health EOS Commercial |
$250.80
|
| Rate for Payer: HFN Commercial |
$261.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$131.58
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: NAPHCARE Commercial |
$197.37
|
| Rate for Payer: Preferred Network Access Commercial |
$261.82
|
| Rate for Payer: Quartz Beloit One Network |
$121.26
|
| Rate for Payer: Quartz Commercial |
$157.09
|
| Rate for Payer: Quartz Medicare Advantage |
$131.58
|
| Rate for Payer: The Alliance Commercial |
$361.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.58
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$230.27
|
|
|
Ko elastic with joints L1810
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$77.17 |
| Max. Negotiated Rate |
$526.32 |
| Rate for Payer: Aetna Commercial |
$248.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Aetna Managed Medicare |
$77.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.07
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$253.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.23
|
| Rate for Payer: Health EOS Commercial |
$245.28
|
| Rate for Payer: HFN Commercial |
$253.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$206.70
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: NAPHCARE Commercial |
$165.36
|
| Rate for Payer: Preferred Network Access Commercial |
$253.55
|
| Rate for Payer: Quartz Beloit One Network |
$135.04
|
| Rate for Payer: Quartz Commercial |
$179.14
|
| Rate for Payer: Quartz Medicare Advantage |
$165.36
|
| Rate for Payer: The Alliance Commercial |
$526.32
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$204.13
|
|
|
Ko elastic with joints L1810
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$135.04 |
| Max. Negotiated Rate |
$253.55 |
| Rate for Payer: Aetna Commercial |
$248.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.07
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$253.55
|
| Rate for Payer: Health EOS Commercial |
$245.28
|
| Rate for Payer: HFN Commercial |
$253.55
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: Preferred Network Access Commercial |
$253.55
|
| Rate for Payer: Quartz Beloit One Network |
$135.04
|
| Rate for Payer: Quartz Commercial |
$165.36
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$204.13
|
|
|
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 |
$81.65 |
| Max. Negotiated Rate |
$309.24 |
| Rate for Payer: Aetna Commercial |
$309.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$81.65
|
| Rate for Payer: Anthem Medicare Advantage |
$81.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$81.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$81.65
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$309.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$162.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.65
|
| Rate for Payer: Health EOS Commercial |
$296.22
|
| Rate for Payer: HFN Commercial |
$309.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$299.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$81.65
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$122.48
|
| Rate for Payer: Preferred Network Access Commercial |
$309.24
|
| Rate for Payer: Quartz Beloit One Network |
$143.23
|
| Rate for Payer: Quartz Commercial |
$185.55
|
| Rate for Payer: Quartz Medicare Advantage |
$81.65
|
| Rate for Payer: The Alliance Commercial |
$224.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.65
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$142.89
|
|
|
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 |
$159.50 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$195.31
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
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 |
$66.13 |
| Max. Negotiated Rate |
$326.60 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$91.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.17
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.14
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$195.31
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$211.59
|
| Rate for Payer: Quartz Medicare Advantage |
$195.31
|
| Rate for Payer: The Alliance Commercial |
$326.60
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
KOH Prep 87220PP
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
3128884
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$103.74 |
| Rate for Payer: Aetna Commercial |
$103.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$99.37
|
| Rate for Payer: HFN Commercial |
$103.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$103.74
|
| Rate for Payer: Quartz Beloit One Network |
$48.05
|
| Rate for Payer: Quartz Commercial |
$62.24
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$19.54
|
|
|
KOH Preparation
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$39.52 |
| Rate for Payer: Aetna Commercial |
$39.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$39.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$37.86
|
| Rate for Payer: HFN Commercial |
$39.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$39.52
|
| Rate for Payer: Quartz Beloit One Network |
$18.30
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$19.54
|
|
|
KOH Preparation
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
KOH Preparation
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.37
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: United Healthcare PPO |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: Wellcare Medicare |
$4.44
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
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 |
$91.21 |
| Max. Negotiated Rate |
$416.12 |
| Rate for Payer: Aetna Commercial |
$313.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$299.62
|
| Rate for Payer: Aetna Managed Medicare |
$97.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.65
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$320.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.97
|
| Rate for Payer: Health EOS Commercial |
$310.08
|
| Rate for Payer: HFN Commercial |
$320.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.30
|
| Rate for Payer: Multiplan Commercial |
$278.72
|
| Rate for Payer: NAPHCARE Commercial |
$209.04
|
| Rate for Payer: Preferred Network Access Commercial |
$320.53
|
| Rate for Payer: Quartz Beloit One Network |
$170.72
|
| Rate for Payer: Quartz Commercial |
$226.46
|
| Rate for Payer: Quartz Medicare Advantage |
$209.04
|
| Rate for Payer: The Alliance Commercial |
$416.12
|
| Rate for Payer: WEA Trust Commercial |
$191.62
|
| Rate for Payer: WPS Commercial |
$258.05
|
|
|
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 |
$104.03 |
| Max. Negotiated Rate |
$383.31 |
| Rate for Payer: Aetna Commercial |
$330.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$299.62
|
| Rate for Payer: Aetna Managed Medicare |
$104.03
|
| Rate for Payer: Anthem Medicare Advantage |
$104.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$104.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$104.03
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$330.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$174.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.03
|
| Rate for Payer: Health EOS Commercial |
$317.04
|
| Rate for Payer: HFN Commercial |
$330.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$383.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$383.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$104.03
|
| Rate for Payer: Multiplan Commercial |
$278.72
|
| Rate for Payer: NAPHCARE Commercial |
$156.05
|
| Rate for Payer: Preferred Network Access Commercial |
$330.98
|
| Rate for Payer: Quartz Beloit One Network |
$153.30
|
| Rate for Payer: Quartz Commercial |
$198.59
|
| Rate for Payer: Quartz Medicare Advantage |
$104.03
|
| Rate for Payer: The Alliance Commercial |
$286.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$104.03
|
| Rate for Payer: WEA Trust Commercial |
$191.62
|
| Rate for Payer: WPS Commercial |
$182.05
|
|
