|
MASK ANESTHESIA UNSCENT SIZE 4 1045
|
Facility
|
OP
|
$64.00
|
|
| Hospital Charge Code |
2974641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$17.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.81
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$38.40
|
| Rate for Payer: The Alliance Commercial |
$256.00
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
MASK ANESTHESIA UNSCENT SIZE 4 1045
|
Facility
|
IP
|
$64.00
|
|
| Hospital Charge Code |
2974641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
MASK BI-LEVEL MEDIUM VERA VENT #1012637
|
Facility
|
IP
|
$567.00
|
|
| Hospital Charge Code |
2974496
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.83 |
| Max. Negotiated Rate |
$521.64 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$340.20
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK BI-LEVEL MEDIUM VERA VENT #1012637
|
Facility
|
OP
|
$567.00
|
|
| Hospital Charge Code |
2974496
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$158.76 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Aetna Managed Medicare |
$158.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$368.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$283.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.29
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$425.25
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$368.55
|
| Rate for Payer: Quartz Medicare Advantage |
$340.20
|
| Rate for Payer: The Alliance Commercial |
$2,268.00
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK FULL FACE LARGE #1012638
|
Facility
|
OP
|
$567.00
|
|
| Hospital Charge Code |
2974497
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$158.76 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Aetna Managed Medicare |
$158.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$368.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$283.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.29
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$425.25
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$368.55
|
| Rate for Payer: Quartz Medicare Advantage |
$340.20
|
| Rate for Payer: The Alliance Commercial |
$2,268.00
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK FULL FACE LARGE #1012638
|
Facility
|
IP
|
$567.00
|
|
| Hospital Charge Code |
2974497
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.83 |
| Max. Negotiated Rate |
$521.64 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$340.20
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK FULL FACE SMALL VENT #1012636
|
Facility
|
IP
|
$567.00
|
|
| Hospital Charge Code |
2974495
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.83 |
| Max. Negotiated Rate |
$521.64 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$340.20
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK FULL FACE SMALL VENT #1012636
|
Facility
|
OP
|
$567.00
|
|
| Hospital Charge Code |
2974495
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$158.76 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna Commercial |
$510.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$487.62
|
| Rate for Payer: Aetna Managed Medicare |
$158.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$368.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$283.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$300.51
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$521.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.29
|
| Rate for Payer: Health EOS Commercial |
$504.63
|
| Rate for Payer: HFN Commercial |
$521.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$425.25
|
| Rate for Payer: Multiplan Commercial |
$453.60
|
| Rate for Payer: NAPHCARE Commercial |
$340.20
|
| Rate for Payer: Preferred Network Access Commercial |
$521.64
|
| Rate for Payer: Quartz Beloit One Network |
$277.83
|
| Rate for Payer: Quartz Commercial |
$368.55
|
| Rate for Payer: Quartz Medicare Advantage |
$340.20
|
| Rate for Payer: The Alliance Commercial |
$2,268.00
|
| Rate for Payer: WEA Trust Commercial |
$311.85
|
| Rate for Payer: WPS Commercial |
$419.98
|
|
|
MASK N95 ORANGE DUCKBILL KC SMALL 46827
|
Facility
|
IP
|
$456.00
|
|
| Hospital Charge Code |
2969087
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
MASK N95 ORANGE DUCKBILL KC SMALL 46827
|
Facility
|
OP
|
$456.00
|
|
| Hospital Charge Code |
2969087
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$127.68 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$127.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.18
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.00
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$273.60
|
| Rate for Payer: The Alliance Commercial |
$1,824.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
MASK PANDA MEDIUM 1293
|
Facility
|
OP
|
$170.00
|
|
| Hospital Charge Code |
2969776
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$47.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.13
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$102.00
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
MASK PANDA MEDIUM 1293
|
Facility
|
IP
|
$170.00
|
|
| Hospital Charge Code |
2969776
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
MASK PANDA SMALL HUD100110S
|
Facility
|
OP
|
$170.00
|
|
| Hospital Charge Code |
2969777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$47.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.13
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.50
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$102.00
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
MASK PANDA SMALL HUD100110S
|
Facility
|
IP
|
$170.00
|
|
| Hospital Charge Code |
2969777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
MASK PED HIGH CONCENTR #1000
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2974751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.99
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
MASK PED HIGH CONCENTR #1000
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2974751
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
MASK PROCEDURE FLUID SHIELD ORANGE 47107
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
2963481
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
MASK PROCEDURE FLUID SHIELD ORANGE 47107
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
2963481
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
MASSAGE CREME 1 GAL BIOTONE #9283-14
|
Facility
|
OP
|
$1,262.00
|
|
| Hospital Charge Code |
2969712
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$353.36 |
| Max. Negotiated Rate |
$5,048.00 |
| Rate for Payer: Aetna Commercial |
$1,135.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,085.32
|
| Rate for Payer: Aetna Managed Medicare |
$353.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$820.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$631.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.86
|
| Rate for Payer: Cash Price |
$378.60
|
| Rate for Payer: Cigna Commercial |
$1,161.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$706.22
|
| Rate for Payer: Health EOS Commercial |
$1,123.18
|
| Rate for Payer: HFN Commercial |
$1,161.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$946.50
|
| Rate for Payer: Multiplan Commercial |
$1,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$757.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,161.04
|
| Rate for Payer: Quartz Beloit One Network |
$618.38
|
| Rate for Payer: Quartz Commercial |
$820.30
|
| Rate for Payer: Quartz Medicare Advantage |
$757.20
|
| Rate for Payer: The Alliance Commercial |
$5,048.00
|
| Rate for Payer: WEA Trust Commercial |
$694.10
|
| Rate for Payer: WPS Commercial |
$934.76
|
|
|
MASSAGE CREME 1 GAL BIOTONE #9283-14
|
Facility
|
IP
|
$1,262.00
|
|
| Hospital Charge Code |
2969712
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$618.38 |
| Max. Negotiated Rate |
$1,161.04 |
| Rate for Payer: Aetna Commercial |
$1,135.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,085.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.86
|
| Rate for Payer: Cash Price |
$378.60
|
| Rate for Payer: Cigna Commercial |
$1,161.04
|
| Rate for Payer: Health EOS Commercial |
$1,123.18
|
| Rate for Payer: HFN Commercial |
$1,161.04
|
| Rate for Payer: Multiplan Commercial |
$1,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$757.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,161.04
|
| Rate for Payer: Quartz Beloit One Network |
$618.38
|
| Rate for Payer: Quartz Commercial |
$757.20
|
| Rate for Payer: WEA Trust Commercial |
$694.10
|
| Rate for Payer: WPS Commercial |
$934.76
|
|
|
MASSAGE CREME & LOTION 1 GAL #9283-16
|
Facility
|
IP
|
$850.00
|
|
| Hospital Charge Code |
2974061
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$782.00 |
| Rate for Payer: Aetna Commercial |
$765.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.50
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$782.00
|
| Rate for Payer: Health EOS Commercial |
$756.50
|
| Rate for Payer: HFN Commercial |
$782.00
|
| Rate for Payer: Multiplan Commercial |
$680.00
|
| Rate for Payer: NAPHCARE Commercial |
$510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$782.00
|
| Rate for Payer: Quartz Beloit One Network |
$416.50
|
| Rate for Payer: Quartz Commercial |
$510.00
|
| Rate for Payer: WEA Trust Commercial |
$467.50
|
| Rate for Payer: WPS Commercial |
$629.60
|
|
|
MASSAGE CREME & LOTION 1 GAL #9283-16
|
Facility
|
OP
|
$850.00
|
|
| Hospital Charge Code |
2974061
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$238.00 |
| Max. Negotiated Rate |
$3,400.00 |
| Rate for Payer: Aetna Commercial |
$765.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$731.00
|
| Rate for Payer: Aetna Managed Medicare |
$238.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$552.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$425.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$408.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.50
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$782.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.66
|
| Rate for Payer: Health EOS Commercial |
$756.50
|
| Rate for Payer: HFN Commercial |
$782.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$637.50
|
| Rate for Payer: Multiplan Commercial |
$680.00
|
| Rate for Payer: NAPHCARE Commercial |
$510.00
|
| Rate for Payer: Preferred Network Access Commercial |
$782.00
|
| Rate for Payer: Quartz Beloit One Network |
$416.50
|
| Rate for Payer: Quartz Commercial |
$552.50
|
| Rate for Payer: Quartz Medicare Advantage |
$510.00
|
| Rate for Payer: The Alliance Commercial |
$3,400.00
|
| Rate for Payer: WEA Trust Commercial |
$467.50
|
| Rate for Payer: WPS Commercial |
$629.60
|
|
|
MASTECTOMY FOR MALIGNANCY WITH CC/MCC
|
Facility
|
IP
|
$46,615.00
|
|
|
Service Code
|
MSDRG 582
|
| Min. Negotiated Rate |
$16,767.83 |
| Max. Negotiated Rate |
$46,615.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,767.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,036.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,855.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,514.26
|
| Rate for Payer: Anthem Medicare Advantage |
$16,767.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,767.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,767.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,767.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,323.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,767.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,508.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,767.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,767.83
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,767.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,767.83
|
| Rate for Payer: NAPHCARE Commercial |
$25,151.74
|
| Rate for Payer: Quartz Medicare Advantage |
$16,767.83
|
| Rate for Payer: The Alliance Commercial |
$46,615.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,767.83
|
| Rate for Payer: United Healthcare PPO |
$25,308.25
|
| Rate for Payer: Wellcare Medicare |
$16,767.83
|
|
|
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$40,782.00
|
|
|
Service Code
|
MSDRG 583
|
| Min. Negotiated Rate |
$14,669.64 |
| Max. Negotiated Rate |
$40,782.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,669.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,443.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,222.56
|
| Rate for Payer: Anthem Medicare Advantage |
$14,669.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,669.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,669.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,669.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,779.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,669.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,677.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,669.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,669.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,669.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,669.64
|
| Rate for Payer: NAPHCARE Commercial |
$22,004.46
|
| Rate for Payer: Quartz Medicare Advantage |
$14,669.64
|
| Rate for Payer: The Alliance Commercial |
$40,782.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,669.64
|
| Rate for Payer: United Healthcare PPO |
$23,103.96
|
| Rate for Payer: Wellcare Medicare |
$14,669.64
|
|
|
MASTECTOMY, MODIFIED RADICAL
|
Facility
|
IP
|
$4,238.00
|
|
| Hospital Charge Code |
2960225
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,076.62 |
| Max. Negotiated Rate |
$3,898.96 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,542.80
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
