|
K-WIRE TWO STEP 0.054 X6 210-54-006
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3715510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$89.40 |
| Max. Negotiated Rate |
$293.74 |
| Rate for Payer: Aetna Commercial |
$287.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.58
|
| Rate for Payer: Aetna Managed Medicare |
$89.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$207.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$153.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.22
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$293.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.67
|
| Rate for Payer: Health EOS Commercial |
$284.16
|
| Rate for Payer: HFN Commercial |
$293.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$239.46
|
| Rate for Payer: Multiplan Commercial |
$255.42
|
| Rate for Payer: NAPHCARE Commercial |
$191.57
|
| Rate for Payer: Preferred Network Access Commercial |
$293.74
|
| Rate for Payer: Quartz Beloit One Network |
$156.45
|
| Rate for Payer: Quartz Commercial |
$207.53
|
| Rate for Payer: Quartz Medicare Advantage |
$191.57
|
| Rate for Payer: The Alliance Commercial |
$159.64
|
| Rate for Payer: WEA Trust Commercial |
$175.60
|
| Rate for Payer: WPS Commercial |
$236.48
|
|
|
K-WIRE TWO STEP 0.054 X6 210-54-006
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3715510
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.45 |
| Max. Negotiated Rate |
$293.74 |
| Rate for Payer: Aetna Commercial |
$287.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.22
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$293.74
|
| Rate for Payer: Health EOS Commercial |
$284.16
|
| Rate for Payer: HFN Commercial |
$293.74
|
| Rate for Payer: Multiplan Commercial |
$255.42
|
| Rate for Payer: Preferred Network Access Commercial |
$293.74
|
| Rate for Payer: Quartz Beloit One Network |
$156.45
|
| Rate for Payer: Quartz Commercial |
$191.57
|
| Rate for Payer: WEA Trust Commercial |
$175.60
|
| Rate for Payer: WPS Commercial |
$236.48
|
|
|
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 |
$1,287.76 |
| Max. Negotiated Rate |
$2,417.83 |
| Rate for Payer: Aetna Commercial |
$2,365.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,260.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,392.88
|
| Rate for Payer: Cash Price |
$758.10
|
| Rate for Payer: Cigna Commercial |
$2,417.83
|
| Rate for Payer: Health EOS Commercial |
$2,338.99
|
| Rate for Payer: HFN Commercial |
$2,417.83
|
| Rate for Payer: Multiplan Commercial |
$2,102.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,417.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,287.76
|
| Rate for Payer: Quartz Commercial |
$1,576.85
|
| Rate for Payer: WEA Trust Commercial |
$1,445.44
|
| Rate for Payer: WPS Commercial |
$1,946.55
|
|
|
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 |
$735.86 |
| Max. Negotiated Rate |
$2,417.83 |
| Rate for Payer: Aetna Commercial |
$2,365.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,260.15
|
| Rate for Payer: Aetna Managed Medicare |
$735.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,708.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,314.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,261.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,392.88
|
| Rate for Payer: Cash Price |
$758.10
|
| Rate for Payer: Cigna Commercial |
$2,417.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,470.71
|
| Rate for Payer: Health EOS Commercial |
$2,338.99
|
| Rate for Payer: HFN Commercial |
$2,417.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,971.06
|
| Rate for Payer: Multiplan Commercial |
$2,102.46
|
| Rate for Payer: NAPHCARE Commercial |
$1,576.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,417.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,287.76
|
| Rate for Payer: Quartz Commercial |
$1,708.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,576.85
|
| Rate for Payer: The Alliance Commercial |
$1,314.04
|
| Rate for Payer: WEA Trust Commercial |
$1,445.44
|
| Rate for Payer: WPS Commercial |
$1,946.55
|
|
|
Kyleena 1 unit Charge
|
Facility
|
OP
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$701.50 |
| Max. Negotiated Rate |
$2,304.93 |
| Rate for Payer: Aetna Commercial |
$2,254.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,154.61
|
| Rate for Payer: Aetna Managed Medicare |
$701.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,628.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,252.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,202.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,327.84
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,304.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,402.04
|
| Rate for Payer: Health EOS Commercial |
$2,229.77
|
| Rate for Payer: HFN Commercial |
$2,304.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,879.02
|
| Rate for Payer: Multiplan Commercial |
$2,004.29
|
| Rate for Payer: NAPHCARE Commercial |
$1,503.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,304.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,227.63
|
| Rate for Payer: Quartz Commercial |
$1,628.48
|
| Rate for Payer: Quartz Medicare Advantage |
$1,503.22
|
| Rate for Payer: The Alliance Commercial |
$1,252.68
|
| Rate for Payer: WEA Trust Commercial |
$1,377.95
|
| Rate for Payer: WPS Commercial |
$1,855.65
|
|
|
Kyleena 1 unit Charge
|
Professional
|
Both
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,039.25 |
| Max. Negotiated Rate |
$2,380.09 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,503.22
|
| Rate for Payer: Aetna Commercial |
$2,380.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,154.61
|
| Rate for Payer: Anthem Commercial |
$1,039.25
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,380.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,263.22
|
| Rate for Payer: Health EOS Commercial |
$2,279.88
|
| Rate for Payer: HFN Commercial |
$2,380.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,547.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,547.66
|
| Rate for Payer: Multiplan Commercial |
$2,004.29
|
| Rate for Payer: Preferred Network Access Commercial |
$2,380.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.36
|
| Rate for Payer: Quartz Commercial |
$1,428.06
|
| Rate for Payer: The Alliance Commercial |
$1,252.68
|
| Rate for Payer: United Healthcare Medicaid |
$1,263.22
|
| Rate for Payer: WEA Trust Commercial |
$1,377.95
|
| Rate for Payer: WPS Commercial |
$1,855.65
|
|
|
Kyleena 1 unit Charge
|
Facility
|
IP
|
$2,409.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5571269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,227.63 |
| Max. Negotiated Rate |
$2,304.93 |
| Rate for Payer: Aetna Commercial |
$2,254.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,154.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,327.84
|
| Rate for Payer: Cash Price |
$722.70
|
| Rate for Payer: Cigna Commercial |
$2,304.93
|
| Rate for Payer: Health EOS Commercial |
$2,229.77
|
| Rate for Payer: HFN Commercial |
$2,304.93
|
| Rate for Payer: Multiplan Commercial |
$2,004.29
|
| Rate for Payer: Preferred Network Access Commercial |
$2,304.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,227.63
|
| Rate for Payer: Quartz Commercial |
$1,503.22
|
| Rate for Payer: WEA Trust Commercial |
$1,377.95
|
| Rate for Payer: WPS Commercial |
$1,855.65
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
IP
|
$2,330.00
|
|
| Hospital Charge Code |
6180102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,187.37 |
| Max. Negotiated Rate |
$2,229.34 |
| Rate for Payer: Aetna Commercial |
$2,180.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,083.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,284.30
|
| Rate for Payer: Cash Price |
$699.00
|
| Rate for Payer: Cigna Commercial |
$2,229.34
|
| Rate for Payer: Health EOS Commercial |
$2,156.65
|
| Rate for Payer: HFN Commercial |
$2,229.34
|
| Rate for Payer: Multiplan Commercial |
$1,938.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,229.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,187.37
|
| Rate for Payer: Quartz Commercial |
$1,453.92
|
| Rate for Payer: WEA Trust Commercial |
$1,332.76
|
| Rate for Payer: WPS Commercial |
$1,794.80
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
OP
|
$2,330.00
|
|
| Hospital Charge Code |
6180102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$678.50 |
| Max. Negotiated Rate |
$2,229.34 |
| Rate for Payer: Aetna Commercial |
$2,180.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,083.95
|
| Rate for Payer: Aetna Managed Medicare |
$678.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,575.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,211.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,163.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,284.30
|
| Rate for Payer: Cash Price |
$699.00
|
| Rate for Payer: Cigna Commercial |
$2,229.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,356.06
|
| Rate for Payer: Health EOS Commercial |
$2,156.65
|
| Rate for Payer: HFN Commercial |
$2,229.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,817.40
|
| Rate for Payer: Multiplan Commercial |
$1,938.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,453.92
|
| Rate for Payer: Preferred Network Access Commercial |
$2,229.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,187.37
|
| Rate for Payer: Quartz Commercial |
$1,575.08
|
| Rate for Payer: Quartz Medicare Advantage |
$1,453.92
|
| Rate for Payer: The Alliance Commercial |
$1,211.60
|
| Rate for Payer: WEA Trust Commercial |
$1,332.76
|
| Rate for Payer: WPS Commercial |
$1,794.80
|
|
|
KYPHOPLASTY LUMBAR ADD LEVEL
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
6180100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$649.23 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$794.98
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
KYPHOPLASTY LUMBAR ADD LEVEL
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
6180100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Aetna Managed Medicare |
$370.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$741.47
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.72
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: NAPHCARE Commercial |
$794.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$861.22
|
| Rate for Payer: Quartz Medicare Advantage |
$794.98
|
| Rate for Payer: The Alliance Commercial |
$662.48
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
OP
|
$2,540.00
|
|
| Hospital Charge Code |
6180103
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$739.65 |
| Max. Negotiated Rate |
$2,430.27 |
| Rate for Payer: Aetna Commercial |
$2,377.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.78
|
| Rate for Payer: Aetna Managed Medicare |
$739.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,717.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,320.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,267.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,400.05
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$2,430.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,478.28
|
| Rate for Payer: Health EOS Commercial |
$2,351.02
|
| Rate for Payer: HFN Commercial |
$2,430.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,981.20
|
| Rate for Payer: Multiplan Commercial |
$2,113.28
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.96
|
| Rate for Payer: Preferred Network Access Commercial |
$2,430.27
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.38
|
| Rate for Payer: Quartz Commercial |
$1,717.04
|
| Rate for Payer: Quartz Medicare Advantage |
$1,584.96
|
| Rate for Payer: The Alliance Commercial |
$1,320.80
|
| Rate for Payer: WEA Trust Commercial |
$1,452.88
|
| Rate for Payer: WPS Commercial |
$1,956.56
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
IP
|
$2,540.00
|
|
| Hospital Charge Code |
6180103
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,294.38 |
| Max. Negotiated Rate |
$2,430.27 |
| Rate for Payer: Aetna Commercial |
$2,377.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,400.05
|
| Rate for Payer: Cash Price |
$762.00
|
| Rate for Payer: Cigna Commercial |
$2,430.27
|
| Rate for Payer: Health EOS Commercial |
$2,351.02
|
| Rate for Payer: HFN Commercial |
$2,430.27
|
| Rate for Payer: Multiplan Commercial |
$2,113.28
|
| Rate for Payer: Preferred Network Access Commercial |
$2,430.27
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.38
|
| Rate for Payer: Quartz Commercial |
$1,584.96
|
| Rate for Payer: WEA Trust Commercial |
$1,452.88
|
| Rate for Payer: WPS Commercial |
$1,956.56
|
|
|
KYPHOPLASTY THORACIC ADD LEVEL
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
6180101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$649.23 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$794.98
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
KYPHOPLASTY THORACIC ADD LEVEL
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
6180101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Aetna Managed Medicare |
$370.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$741.47
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.72
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: NAPHCARE Commercial |
$794.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$861.22
|
| Rate for Payer: Quartz Medicare Advantage |
$794.98
|
| Rate for Payer: The Alliance Commercial |
$662.48
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
LABELS AND MARKER STERILE 3334-P
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2962812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
LABELS AND MARKER STERILE 3334-P
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2962812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
LABOR AND DELIVERY RELATED DIAGNOSES
|
Facility
|
OP
|
$52.93
|
|
|
Service Code
|
EAPG 00760
|
| Min. Negotiated Rate |
$50.90 |
| Max. Negotiated Rate |
$52.93 |
| Rate for Payer: Anthem Medicaid |
$50.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$50.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.90
|
| Rate for Payer: Dean Health Medicaid |
$50.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50.90
|
| Rate for Payer: Managed Health Services Medicaid |
$52.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.90
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$50.90
|
| Rate for Payer: United Healthcare Medicaid |
$50.90
|
|
|
LABRALTAPE 1.5MM WHITE/BLACK AR-7276T
|
Facility
|
OP
|
$1,230.00
|
|
| Hospital Charge Code |
5107166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$358.18 |
| Max. Negotiated Rate |
$1,176.86 |
| Rate for Payer: Aetna Commercial |
$1,151.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.11
|
| Rate for Payer: Aetna Managed Medicare |
$358.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$831.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$639.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$614.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$677.98
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$1,176.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$715.86
|
| Rate for Payer: Health EOS Commercial |
$1,138.49
|
| Rate for Payer: HFN Commercial |
$1,176.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$959.40
|
| Rate for Payer: Multiplan Commercial |
$1,023.36
|
| Rate for Payer: NAPHCARE Commercial |
$767.52
|
| Rate for Payer: Preferred Network Access Commercial |
$1,176.86
|
| Rate for Payer: Quartz Beloit One Network |
$626.81
|
| Rate for Payer: Quartz Commercial |
$831.48
|
| Rate for Payer: Quartz Medicare Advantage |
$767.52
|
| Rate for Payer: The Alliance Commercial |
$639.60
|
| Rate for Payer: WEA Trust Commercial |
$703.56
|
| Rate for Payer: WPS Commercial |
$947.47
|
|
|
LABRALTAPE 1.5MM WHITE/BLACK AR-7276T
|
Facility
|
IP
|
$1,230.00
|
|
| Hospital Charge Code |
5107166
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$626.81 |
| Max. Negotiated Rate |
$1,176.86 |
| Rate for Payer: Aetna Commercial |
$1,151.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$677.98
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$1,176.86
|
| Rate for Payer: Health EOS Commercial |
$1,138.49
|
| Rate for Payer: HFN Commercial |
$1,176.86
|
| Rate for Payer: Multiplan Commercial |
$1,023.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,176.86
|
| Rate for Payer: Quartz Beloit One Network |
$626.81
|
| Rate for Payer: Quartz Commercial |
$767.52
|
| Rate for Payer: WEA Trust Commercial |
$703.56
|
| Rate for Payer: WPS Commercial |
$947.47
|
|
|
LABYRINTHECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960165
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
LABYRINTHECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960165
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
Lacosamide
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$114.61 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Lacosamide
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$72.38
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
Lacosamide
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
983298
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$78.42
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
