|
0031A Janssen - Covid Admin Charge
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
0031A Janssen - Covid Admin Charge
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$46.68 |
| Max. Negotiated Rate |
$100.78 |
| Rate for Payer: Aetna Commercial |
$100.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$100.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.65
|
| Rate for Payer: Health EOS Commercial |
$96.53
|
| Rate for Payer: HFN Commercial |
$100.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.94
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$100.78
|
| Rate for Payer: Quartz Beloit One Network |
$46.68
|
| Rate for Payer: Quartz Commercial |
$60.47
|
| Rate for Payer: The Alliance Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.00
|
|
|
0031A Janssen - Covid Admin Charge
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 0031A
|
| Hospital Charge Code |
5727748
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$29.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.36
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.56
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$63.65
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$68.95
|
| Rate for Payer: Quartz Medicare Advantage |
$63.65
|
| Rate for Payer: The Alliance Commercial |
$53.04
|
| Rate for Payer: United Healthcare PPO |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
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 |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
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 |
$16.31 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: United Healthcare PPO |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
0034A Janssen (BOOSTER) - Covid Admin Charge
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 0034A
|
| Hospital Charge Code |
5907628
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.63 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.94
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$78.00
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Professional
|
Both
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$25.63 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.94
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
0082A Pfizer (PEDS 0.2ml) - Covid Admin Chg-Pfizer
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
6182252
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
.014 AllStar J Tip 190cm
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$108.04 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Aetna Managed Medicare |
$108.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.92
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.38
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: NAPHCARE Commercial |
$231.50
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$250.80
|
| Rate for Payer: Quartz Medicare Advantage |
$231.50
|
| Rate for Payer: The Alliance Commercial |
$192.92
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 AllStar J Tip 190cm
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.06 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$231.50
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 AllStar J Tip 190cm
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.77 |
| Max. Negotiated Rate |
$366.55 |
| Rate for Payer: Aetna Commercial |
$366.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$366.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.50
|
| Rate for Payer: Health EOS Commercial |
$351.11
|
| Rate for Payer: HFN Commercial |
$366.55
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$366.55
|
| Rate for Payer: Quartz Beloit One Network |
$169.77
|
| Rate for Payer: Quartz Commercial |
$219.93
|
| Rate for Payer: The Alliance Commercial |
$192.92
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 AllStar J Tip 300cm
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$132.70 |
| Max. Negotiated Rate |
$286.52 |
| Rate for Payer: Aetna Commercial |
$286.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$286.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.96
|
| Rate for Payer: Health EOS Commercial |
$274.46
|
| Rate for Payer: HFN Commercial |
$286.52
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$286.52
|
| Rate for Payer: Quartz Beloit One Network |
$132.70
|
| Rate for Payer: Quartz Commercial |
$171.91
|
| Rate for Payer: The Alliance Commercial |
$150.80
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 AllStar J Tip 300cm
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$84.45 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Aetna Managed Medicare |
$84.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.78
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.20
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: NAPHCARE Commercial |
$180.96
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$196.04
|
| Rate for Payer: Quartz Medicare Advantage |
$180.96
|
| Rate for Payer: The Alliance Commercial |
$150.80
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 AllStar J Tip 300cm
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.78 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 ALL-STAR WIRE
|
Facility
|
IP
|
$1,731.00
|
|
| Hospital Charge Code |
6175147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$882.12 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,080.14
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
.014 ALL-STAR WIRE
|
Facility
|
OP
|
$1,731.00
|
|
| Hospital Charge Code |
6175147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.07 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Aetna Managed Medicare |
$504.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,007.44
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.18
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,170.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.14
|
| Rate for Payer: The Alliance Commercial |
$900.12
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
.014 BMW J Tip 190cm
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.06 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$231.50
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 BMW J Tip 190cm
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$108.04 |
| Max. Negotiated Rate |
$354.97 |
| Rate for Payer: Aetna Commercial |
$347.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Aetna Managed Medicare |
$108.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$185.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.50
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$354.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.92
|
| Rate for Payer: Health EOS Commercial |
$343.40
|
| Rate for Payer: HFN Commercial |
$354.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$289.38
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: NAPHCARE Commercial |
$231.50
|
| Rate for Payer: Preferred Network Access Commercial |
$354.97
|
| Rate for Payer: Quartz Beloit One Network |
$189.06
|
| Rate for Payer: Quartz Commercial |
$250.80
|
| Rate for Payer: Quartz Medicare Advantage |
$231.50
|
| Rate for Payer: The Alliance Commercial |
$192.92
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 BMW J Tip 190cm
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158932
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$169.77 |
| Max. Negotiated Rate |
$366.55 |
| Rate for Payer: Aetna Commercial |
$366.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.82
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$366.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.50
|
| Rate for Payer: Health EOS Commercial |
$351.11
|
| Rate for Payer: HFN Commercial |
$366.55
|
| Rate for Payer: Multiplan Commercial |
$308.67
|
| Rate for Payer: Preferred Network Access Commercial |
$366.55
|
| Rate for Payer: Quartz Beloit One Network |
$169.77
|
| Rate for Payer: Quartz Commercial |
$219.93
|
| Rate for Payer: The Alliance Commercial |
$192.92
|
| Rate for Payer: WEA Trust Commercial |
$212.21
|
| Rate for Payer: WPS Commercial |
$285.78
|
|
|
.014 BMW J Tip 300cm
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$84.45 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Aetna Managed Medicare |
$84.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.78
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.20
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: NAPHCARE Commercial |
$180.96
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$196.04
|
| Rate for Payer: Quartz Medicare Advantage |
$180.96
|
| Rate for Payer: The Alliance Commercial |
$150.80
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 BMW J Tip 300cm
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$132.70 |
| Max. Negotiated Rate |
$286.52 |
| Rate for Payer: Aetna Commercial |
$286.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$286.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.96
|
| Rate for Payer: Health EOS Commercial |
$274.46
|
| Rate for Payer: HFN Commercial |
$286.52
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$286.52
|
| Rate for Payer: Quartz Beloit One Network |
$132.70
|
| Rate for Payer: Quartz Commercial |
$171.91
|
| Rate for Payer: The Alliance Commercial |
$150.80
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 BMW J Tip 300cm
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158934
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.78 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
.014 CHOICE ES GUIDEWIRE
|
Facility
|
IP
|
$1,019.00
|
|
| Hospital Charge Code |
6175144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$519.28 |
| Max. Negotiated Rate |
$974.98 |
| Rate for Payer: Aetna Commercial |
$953.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.67
|
| Rate for Payer: Cash Price |
$305.70
|
| Rate for Payer: Cigna Commercial |
$974.98
|
| Rate for Payer: Health EOS Commercial |
$943.19
|
| Rate for Payer: HFN Commercial |
$974.98
|
| Rate for Payer: Multiplan Commercial |
$847.81
|
| Rate for Payer: Preferred Network Access Commercial |
$974.98
|
| Rate for Payer: Quartz Beloit One Network |
$519.28
|
| Rate for Payer: Quartz Commercial |
$635.86
|
| Rate for Payer: WEA Trust Commercial |
$582.87
|
| Rate for Payer: WPS Commercial |
$784.94
|
|
|
.014 CHOICE ES GUIDEWIRE
|
Facility
|
OP
|
$1,019.00
|
|
| Hospital Charge Code |
6175144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$296.73 |
| Max. Negotiated Rate |
$974.98 |
| Rate for Payer: Aetna Commercial |
$953.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.39
|
| Rate for Payer: Aetna Managed Medicare |
$296.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$688.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$529.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$508.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.67
|
| Rate for Payer: Cash Price |
$305.70
|
| Rate for Payer: Cigna Commercial |
$974.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$593.06
|
| Rate for Payer: Health EOS Commercial |
$943.19
|
| Rate for Payer: HFN Commercial |
$974.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$794.82
|
| Rate for Payer: Multiplan Commercial |
$847.81
|
| Rate for Payer: NAPHCARE Commercial |
$635.86
|
| Rate for Payer: Preferred Network Access Commercial |
$974.98
|
| Rate for Payer: Quartz Beloit One Network |
$519.28
|
| Rate for Payer: Quartz Commercial |
$688.84
|
| Rate for Payer: Quartz Medicare Advantage |
$635.86
|
| Rate for Payer: The Alliance Commercial |
$529.88
|
| Rate for Payer: WEA Trust Commercial |
$582.87
|
| Rate for Payer: WPS Commercial |
$784.94
|
|
