|
0031A Janssen - Covid Admin Charge
|
Facility
IP
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
0031A Janssen - Covid Admin Charge
|
Professional
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.20
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.71
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: The Alliance Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.00
|
|
|
0031A Janssen - Covid Admin Charge
|
Facility
OP
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$28.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$61.20
|
| Rate for Payer: The Alliance Commercial |
$408.00
|
| Rate for Payer: United Healthcare PPO |
$76.50
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
0034A Janssen (BOOSTER) - Covid Admin Charge
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
CPT 0034A
|
| Hospital Charge Code |
5907628
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
0034A Janssen (BOOSTER) - Covid Admin Charge
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
CPT 0034A
|
| Hospital Charge Code |
5907628
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
0034A Janssen (BOOSTER) - Covid Admin Charge
|
Professional
|
$56.00
|
|
|
Service Code
|
CPT 0034A
|
| Hospital Charge Code |
5907628
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$75.00
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Professional
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Facility
OP
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Facility
IP
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
.014 AllStar J Tip 190cm
|
Facility
IP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$181.79 |
| Max. Negotiated Rate |
$341.32 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$222.60
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$222.60
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 AllStar J Tip 190cm
|
Professional
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.24 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Aetna Commercial |
$352.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$352.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.60
|
| Rate for Payer: Health EOS Commercial |
$337.61
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.45
|
| Rate for Payer: Quartz Beloit One Network |
$163.24
|
| Rate for Payer: Quartz Commercial |
$211.47
|
| Rate for Payer: The Alliance Commercial |
$185.50
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 AllStar J Tip 190cm
|
Facility
OP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.88 |
| Max. Negotiated Rate |
$341.32 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Aetna Managed Medicare |
$103.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$241.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$178.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.61
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$278.25
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$222.60
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$241.15
|
| Rate for Payer: Quartz Medicare Advantage |
$222.60
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 AllStar J Tip 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 AllStar J Tip 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 AllStar J Tip 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 ALL-STAR WIRE
|
Facility
IP
|
$1,731.00
|
|
| Hospital Charge Code |
6175147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$848.19 |
| Max. Negotiated Rate |
$1,592.52 |
| Rate for Payer: Aetna Commercial |
$1,557.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.43
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,592.52
|
| Rate for Payer: Health EOS Commercial |
$1,540.59
|
| Rate for Payer: HFN Commercial |
$1,592.52
|
| Rate for Payer: Multiplan Commercial |
$1,384.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,038.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,592.52
|
| Rate for Payer: Quartz Beloit One Network |
$848.19
|
| Rate for Payer: Quartz Commercial |
$1,038.60
|
| Rate for Payer: WEA Trust Commercial |
$952.05
|
| Rate for Payer: WPS Commercial |
$1,282.15
|
|
|
.014 ALL-STAR WIRE
|
Facility
OP
|
$1,731.00
|
|
| Hospital Charge Code |
6175147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.68 |
| Max. Negotiated Rate |
$6,924.00 |
| Rate for Payer: Aetna Managed Medicare |
$484.68
|
| Rate for Payer: Aetna Commercial |
$1,557.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,488.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,125.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$865.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$830.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$917.43
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,592.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$968.67
|
| Rate for Payer: Health EOS Commercial |
$1,540.59
|
| Rate for Payer: HFN Commercial |
$1,592.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,298.25
|
| Rate for Payer: Multiplan Commercial |
$1,384.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,038.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,592.52
|
| Rate for Payer: Quartz Beloit One Network |
$848.19
|
| Rate for Payer: Quartz Commercial |
$1,125.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,038.60
|
| Rate for Payer: The Alliance Commercial |
$6,924.00
|
| Rate for Payer: WEA Trust Commercial |
$952.05
|
| Rate for Payer: WPS Commercial |
$1,282.15
|
|
|
.014 BMW J Tip 190cm
|
Facility
OP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.88 |
| Max. Negotiated Rate |
$341.32 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Aetna Managed Medicare |
$103.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$241.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$178.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.61
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$278.25
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$222.60
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$241.15
|
| Rate for Payer: Quartz Medicare Advantage |
$222.60
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 BMW J Tip 190cm
|
Professional
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.24 |
| Max. Negotiated Rate |
$352.45 |
| Rate for Payer: Aetna Commercial |
$352.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$352.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.60
|
| Rate for Payer: Health EOS Commercial |
$337.61
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.45
|
| Rate for Payer: Quartz Beloit One Network |
$163.24
|
| Rate for Payer: Quartz Commercial |
$211.47
|
| Rate for Payer: The Alliance Commercial |
$185.50
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 BMW J Tip 190cm
|
Facility
IP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$181.79 |
| Max. Negotiated Rate |
$341.32 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$222.60
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$222.60
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
.014 BMW J Tip 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 BMW J Tip 300cm
|
Professional
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.00
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: The Alliance Commercial |
$145.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 BMW J Tip 300cm
|
Facility
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.10 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
.014 CHOICE ES GUIDEWIRE
|
Facility
OP
|
$1,019.00
|
|
| Hospital Charge Code |
6175144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$285.32 |
| Max. Negotiated Rate |
$4,076.00 |
| Rate for Payer: Aetna Commercial |
$917.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$876.34
|
| Rate for Payer: Aetna Managed Medicare |
$285.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$662.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$509.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$489.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.07
|
| Rate for Payer: Cash Price |
$305.70
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$570.23
|
| Rate for Payer: Health EOS Commercial |
$906.91
|
| Rate for Payer: HFN Commercial |
$937.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$764.25
|
| Rate for Payer: Multiplan Commercial |
$815.20
|
| Rate for Payer: NAPHCARE Commercial |
$611.40
|
| Rate for Payer: Preferred Network Access Commercial |
$937.48
|
| Rate for Payer: Quartz Beloit One Network |
$499.31
|
| Rate for Payer: Quartz Commercial |
$662.35
|
| Rate for Payer: Quartz Medicare Advantage |
$611.40
|
| Rate for Payer: The Alliance Commercial |
$4,076.00
|
| Rate for Payer: WEA Trust Commercial |
$560.45
|
| Rate for Payer: WPS Commercial |
$754.77
|
|
|
.014 CHOICE ES GUIDEWIRE
|
Facility
IP
|
$1,019.00
|
|
| Hospital Charge Code |
6175144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$499.31 |
| Max. Negotiated Rate |
$937.48 |
| Rate for Payer: Aetna Commercial |
$917.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.07
|
| Rate for Payer: Cash Price |
$305.70
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: Health EOS Commercial |
$906.91
|
| Rate for Payer: HFN Commercial |
$937.48
|
| Rate for Payer: Multiplan Commercial |
$815.20
|
| Rate for Payer: NAPHCARE Commercial |
$611.40
|
| Rate for Payer: Preferred Network Access Commercial |
$937.48
|
| Rate for Payer: Quartz Beloit One Network |
$499.31
|
| Rate for Payer: Quartz Commercial |
$611.40
|
| Rate for Payer: WEA Trust Commercial |
$560.45
|
| Rate for Payer: WPS Commercial |
$754.77
|
|
