|
NUT BUTRESS COMPRESSION
|
Facility
|
IP
|
$2,078.00
|
|
| Hospital Charge Code |
2966306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,018.22 |
| Max. Negotiated Rate |
$1,911.76 |
| Rate for Payer: Aetna Commercial |
$1,870.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,787.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,101.34
|
| Rate for Payer: Cash Price |
$623.40
|
| Rate for Payer: Cigna Commercial |
$1,911.76
|
| Rate for Payer: Health EOS Commercial |
$1,849.42
|
| Rate for Payer: HFN Commercial |
$1,911.76
|
| Rate for Payer: Multiplan Commercial |
$1,662.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,246.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,911.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,018.22
|
| Rate for Payer: Quartz Commercial |
$1,246.80
|
| Rate for Payer: WEA Trust Commercial |
$1,142.90
|
| Rate for Payer: WPS Commercial |
$1,539.17
|
|
|
NUT CONNECTING M6 HOFFMANN LIMB 4933-1-701
|
Facility
|
OP
|
$353.00
|
|
| Hospital Charge Code |
6001644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.84 |
| Max. Negotiated Rate |
$1,412.00 |
| Rate for Payer: Aetna Commercial |
$317.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.58
|
| Rate for Payer: Aetna Managed Medicare |
$98.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$229.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$176.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.09
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cigna Commercial |
$324.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.54
|
| Rate for Payer: Health EOS Commercial |
$314.17
|
| Rate for Payer: HFN Commercial |
$324.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$264.75
|
| Rate for Payer: Multiplan Commercial |
$282.40
|
| Rate for Payer: NAPHCARE Commercial |
$211.80
|
| Rate for Payer: Preferred Network Access Commercial |
$324.76
|
| Rate for Payer: Quartz Beloit One Network |
$172.97
|
| Rate for Payer: Quartz Commercial |
$229.45
|
| Rate for Payer: Quartz Medicare Advantage |
$211.80
|
| Rate for Payer: The Alliance Commercial |
$1,412.00
|
| Rate for Payer: WEA Trust Commercial |
$194.15
|
| Rate for Payer: WPS Commercial |
$261.47
|
|
|
NUT CONNECTING M6 HOFFMANN LIMB 4933-1-701
|
Facility
|
IP
|
$353.00
|
|
| Hospital Charge Code |
6001644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$172.97 |
| Max. Negotiated Rate |
$324.76 |
| Rate for Payer: Aetna Commercial |
$317.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.09
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cigna Commercial |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$314.17
|
| Rate for Payer: HFN Commercial |
$324.76
|
| Rate for Payer: Multiplan Commercial |
$282.40
|
| Rate for Payer: NAPHCARE Commercial |
$211.80
|
| Rate for Payer: Preferred Network Access Commercial |
$324.76
|
| Rate for Payer: Quartz Beloit One Network |
$172.97
|
| Rate for Payer: Quartz Commercial |
$211.80
|
| Rate for Payer: WEA Trust Commercial |
$194.15
|
| Rate for Payer: WPS Commercial |
$261.47
|
|
|
NUT SPRING-LOADED 393.43
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
5811624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$540.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Aetna Managed Medicare |
$168.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$390.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$300.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$288.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$552.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$335.76
|
| Rate for Payer: Health EOS Commercial |
$534.00
|
| Rate for Payer: HFN Commercial |
$552.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: NAPHCARE Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$552.00
|
| Rate for Payer: Quartz Beloit One Network |
$294.00
|
| Rate for Payer: Quartz Commercial |
$390.00
|
| Rate for Payer: Quartz Medicare Advantage |
$360.00
|
| Rate for Payer: The Alliance Commercial |
$2,400.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
NUT SPRING-LOADED 393.43
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
5811624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$540.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$552.00
|
| Rate for Payer: Health EOS Commercial |
$534.00
|
| Rate for Payer: HFN Commercial |
$552.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: NAPHCARE Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$552.00
|
| Rate for Payer: Quartz Beloit One Network |
$294.00
|
| Rate for Payer: Quartz Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
O2 Hood with Blender/Humidifier - Daily Charges
|
Facility
|
IP
|
$1,007.00
|
|
| Hospital Charge Code |
3003960
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$493.43 |
| Max. Negotiated Rate |
$926.44 |
| Rate for Payer: Aetna Commercial |
$906.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$866.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.71
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$926.44
|
| Rate for Payer: Health EOS Commercial |
$896.23
|
| Rate for Payer: HFN Commercial |
$926.44
|
| Rate for Payer: Multiplan Commercial |
$805.60
|
| Rate for Payer: NAPHCARE Commercial |
$604.20
|
| Rate for Payer: Preferred Network Access Commercial |
$926.44
|
| Rate for Payer: Quartz Beloit One Network |
$493.43
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: WEA Trust Commercial |
$553.85
|
| Rate for Payer: WPS Commercial |
$745.88
|
|
|
O2 Hood with Blender/Humidifier - Daily Charges
|
Facility
|
OP
|
$1,007.00
|
|
| Hospital Charge Code |
3003960
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$281.96 |
| Max. Negotiated Rate |
$4,028.00 |
| Rate for Payer: Aetna Commercial |
$906.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$866.02
|
| Rate for Payer: Aetna Managed Medicare |
$281.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$654.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$483.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.71
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$926.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$563.52
|
| Rate for Payer: Health EOS Commercial |
$896.23
|
| Rate for Payer: HFN Commercial |
$926.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$755.25
|
| Rate for Payer: Multiplan Commercial |
$805.60
|
| Rate for Payer: NAPHCARE Commercial |
$604.20
|
| Rate for Payer: Preferred Network Access Commercial |
$926.44
|
| Rate for Payer: Quartz Beloit One Network |
$493.43
|
| Rate for Payer: Quartz Commercial |
$654.55
|
| Rate for Payer: Quartz Medicare Advantage |
$604.20
|
| Rate for Payer: The Alliance Commercial |
$4,028.00
|
| Rate for Payer: United Healthcare PPO |
$755.25
|
| Rate for Payer: WEA Trust Commercial |
$553.85
|
| Rate for Payer: WPS Commercial |
$745.88
|
|
|
O2 Hood with Blender/Humidifier - Nursery Daily Charges
|
Facility
|
IP
|
$930.00
|
|
| Hospital Charge Code |
3003952
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$455.70 |
| Max. Negotiated Rate |
$855.60 |
| Rate for Payer: Aetna Commercial |
$837.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$799.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$492.90
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$855.60
|
| Rate for Payer: Health EOS Commercial |
$827.70
|
| Rate for Payer: HFN Commercial |
$855.60
|
| Rate for Payer: Multiplan Commercial |
$744.00
|
| Rate for Payer: NAPHCARE Commercial |
$558.00
|
| Rate for Payer: Preferred Network Access Commercial |
$855.60
|
| Rate for Payer: Quartz Beloit One Network |
$455.70
|
| Rate for Payer: Quartz Commercial |
$558.00
|
| Rate for Payer: WEA Trust Commercial |
$511.50
|
| Rate for Payer: WPS Commercial |
$688.85
|
|
|
O2 Hood with Blender/Humidifier - Nursery Daily Charges
|
Facility
|
OP
|
$930.00
|
|
| Hospital Charge Code |
3003952
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$260.40 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$837.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$799.80
|
| Rate for Payer: Aetna Managed Medicare |
$260.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$604.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$465.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$446.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$492.90
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$855.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$520.43
|
| Rate for Payer: Health EOS Commercial |
$827.70
|
| Rate for Payer: HFN Commercial |
$855.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$697.50
|
| Rate for Payer: Multiplan Commercial |
$744.00
|
| Rate for Payer: NAPHCARE Commercial |
$558.00
|
| Rate for Payer: Preferred Network Access Commercial |
$855.60
|
| Rate for Payer: Quartz Beloit One Network |
$455.70
|
| Rate for Payer: Quartz Commercial |
$604.50
|
| Rate for Payer: Quartz Medicare Advantage |
$558.00
|
| Rate for Payer: The Alliance Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare PPO |
$697.50
|
| Rate for Payer: WEA Trust Commercial |
$511.50
|
| Rate for Payer: WPS Commercial |
$688.85
|
|
|
OAE Limited
|
Professional
|
Both
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$56.81 |
| Max. Negotiated Rate |
$390.45 |
| Rate for Payer: Aetna Commercial |
$390.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$353.46
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$390.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.60
|
| Rate for Payer: Health EOS Commercial |
$374.01
|
| Rate for Payer: HFN Commercial |
$390.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.32
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: Preferred Network Access Commercial |
$390.45
|
| Rate for Payer: Quartz Beloit One Network |
$180.84
|
| Rate for Payer: Quartz Commercial |
$234.27
|
| Rate for Payer: The Alliance Commercial |
$205.50
|
| Rate for Payer: United Healthcare Medicaid |
$56.81
|
| Rate for Payer: WEA Trust Commercial |
$226.05
|
| Rate for Payer: WPS Commercial |
$304.43
|
|
|
OAE Limited
|
Facility
|
OP
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$197.28 |
| Max. Negotiated Rate |
$1,240.96 |
| Rate for Payer: Aetna Commercial |
$369.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$353.46
|
| Rate for Payer: Aetna Managed Medicare |
$310.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$267.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$205.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$197.28
|
| Rate for Payer: Anthem Medicare Advantage |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$310.24
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$378.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$310.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$310.24
|
| Rate for Payer: Health EOS Commercial |
$365.79
|
| Rate for Payer: HFN Commercial |
$378.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$310.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$310.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$310.24
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: NAPHCARE Commercial |
$465.36
|
| Rate for Payer: Preferred Network Access Commercial |
$378.12
|
| Rate for Payer: Quartz Beloit One Network |
$201.39
|
| Rate for Payer: Quartz Commercial |
$267.15
|
| Rate for Payer: Quartz Medicare Advantage |
$310.24
|
| Rate for Payer: The Alliance Commercial |
$1,240.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.24
|
| Rate for Payer: United Healthcare PPO |
$308.25
|
| Rate for Payer: WEA Trust Commercial |
$226.05
|
| Rate for Payer: Wellcare Medicare |
$310.24
|
| Rate for Payer: WPS Commercial |
$304.43
|
|
|
OAE Limited
|
Facility
|
IP
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$201.39 |
| Max. Negotiated Rate |
$378.12 |
| Rate for Payer: Aetna Commercial |
$369.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$353.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.83
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$378.12
|
| Rate for Payer: Health EOS Commercial |
$365.79
|
| Rate for Payer: HFN Commercial |
$378.12
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: NAPHCARE Commercial |
$246.60
|
| Rate for Payer: Preferred Network Access Commercial |
$378.12
|
| Rate for Payer: Quartz Beloit One Network |
$201.39
|
| Rate for Payer: Quartz Commercial |
$246.60
|
| Rate for Payer: WEA Trust Commercial |
$226.05
|
| Rate for Payer: WPS Commercial |
$304.43
|
|
|
Oasis Burn Matrix per sq sm Q4103
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS Q4103
|
| Hospital Charge Code |
6182398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$34.21 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.56
|
| Rate for Payer: Health EOS Commercial |
$19.11
|
| Rate for Payer: HFN Commercial |
$19.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.21
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$19.95
|
| Rate for Payer: Quartz Beloit One Network |
$9.24
|
| Rate for Payer: Quartz Commercial |
$11.97
|
| Rate for Payer: The Alliance Commercial |
$10.50
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$31.40
|
|
|
Oasis Burn Matrix per sq sm Q4103
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS Q4103
|
| Hospital Charge Code |
6182398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$12.60
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Oasis Burn Matrix per sq sm Q4103
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS Q4103
|
| Hospital Charge Code |
6182398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.62
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.75
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$13.65
|
| Rate for Payer: Quartz Medicare Advantage |
$12.60
|
| Rate for Payer: The Alliance Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$31.40
|
|
|
Oasis Ultra tri-layer Matrix, per sq cm Q4124
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5272897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.97
|
| Rate for Payer: Health EOS Commercial |
$98.28
|
| Rate for Payer: HFN Commercial |
$102.60
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$102.60
|
| Rate for Payer: Quartz Beloit One Network |
$47.52
|
| Rate for Payer: Quartz Commercial |
$61.56
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
Oasis Ultra tri-layer Matrix, per sq cm Q4124
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5272897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.92 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$64.80
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Oasis Ultra tri-layer Matrix, per sq cm Q4124
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS Q4124
|
| Hospital Charge Code |
5272897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Aetna Managed Medicare |
$30.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.86
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$70.20
|
| Rate for Payer: Quartz Medicare Advantage |
$64.80
|
| Rate for Payer: The Alliance Commercial |
$432.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$22.42
|
|
|
Observation 1st Hour Direct Admit
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3298772
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$6,992.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$634.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,992.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,030.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,729.00
|
| Rate for Payer: Anthem Medicare Advantage |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$634.87
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$634.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$634.87
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,361.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$634.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$634.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$634.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$634.87
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$952.30
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$634.87
|
| Rate for Payer: The Alliance Commercial |
$2,539.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$634.87
|
| Rate for Payer: United Healthcare PPO |
$2,598.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: Wellcare Medicare |
$634.87
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Observation 1st Hour Direct Admit
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3298772
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Obstetric Panel
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$952.20 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Aetna Managed Medicare |
$47.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.36
|
| Rate for Payer: Anthem Medicaid |
$18.84
|
| Rate for Payer: Anthem Medicare Advantage |
$47.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$548.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.81
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$952.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$47.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$579.19
|
| Rate for Payer: Dean Health Medicaid |
$18.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$47.81
|
| Rate for Payer: Health EOS Commercial |
$921.15
|
| Rate for Payer: HFN Commercial |
$952.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.81
|
| Rate for Payer: Managed Health Services Medicaid |
$19.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$47.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$47.81
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: NAPHCARE Commercial |
$71.72
|
| Rate for Payer: Preferred Network Access Commercial |
$952.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.84
|
| Rate for Payer: Quartz Beloit One Network |
$507.15
|
| Rate for Payer: Quartz Commercial |
$672.75
|
| Rate for Payer: Quartz Medicare Advantage |
$47.81
|
| Rate for Payer: The Alliance Commercial |
$191.24
|
| Rate for Payer: United Healthcare Medicaid |
$18.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.81
|
| Rate for Payer: United Healthcare PPO |
$776.25
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: Wellcare Medicare |
$47.81
|
| Rate for Payer: WMAP Medicaid |
$18.84
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
Obstetric Panel
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$507.15 |
| Max. Negotiated Rate |
$952.20 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$548.55
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$952.20
|
| Rate for Payer: Health EOS Commercial |
$921.15
|
| Rate for Payer: HFN Commercial |
$952.20
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: NAPHCARE Commercial |
$621.00
|
| Rate for Payer: Preferred Network Access Commercial |
$952.20
|
| Rate for Payer: Quartz Beloit One Network |
$507.15
|
| Rate for Payer: Quartz Commercial |
$621.00
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
Obstetric Panel
|
Professional
|
Both
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$168.77 |
| Max. Negotiated Rate |
$983.25 |
| Rate for Payer: Aetna Commercial |
$983.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$983.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$517.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$621.00
|
| Rate for Payer: Health EOS Commercial |
$941.85
|
| Rate for Payer: HFN Commercial |
$983.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.77
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: Preferred Network Access Commercial |
$983.25
|
| Rate for Payer: Quartz Beloit One Network |
$455.40
|
| Rate for Payer: Quartz Commercial |
$589.95
|
| Rate for Payer: The Alliance Commercial |
$517.50
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
Obtaining Screen Pap Smear Q0091
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS Q0091
|
| Hospital Charge Code |
3157531
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$145.65 |
| Rate for Payer: Aetna Commercial |
$66.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.00
|
| Rate for Payer: Health EOS Commercial |
$63.70
|
| Rate for Payer: HFN Commercial |
$66.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$145.65
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: Preferred Network Access Commercial |
$66.50
|
| Rate for Payer: Quartz Beloit One Network |
$30.80
|
| Rate for Payer: Quartz Commercial |
$39.90
|
| Rate for Payer: The Alliance Commercial |
$35.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
OBTURATOR FLEXIBLE AR-2275
|
Facility
|
OP
|
$2,383.00
|
|
| Hospital Charge Code |
5591320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$667.24 |
| Max. Negotiated Rate |
$9,532.00 |
| Rate for Payer: Aetna Commercial |
$2,144.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,049.38
|
| Rate for Payer: Aetna Managed Medicare |
$667.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,548.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,191.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,143.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,262.99
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,192.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,333.53
|
| Rate for Payer: Health EOS Commercial |
$2,120.87
|
| Rate for Payer: HFN Commercial |
$2,192.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,787.25
|
| Rate for Payer: Multiplan Commercial |
$1,906.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,429.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,192.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,167.67
|
| Rate for Payer: Quartz Commercial |
$1,548.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,429.80
|
| Rate for Payer: The Alliance Commercial |
$9,532.00
|
| Rate for Payer: WEA Trust Commercial |
$1,310.65
|
| Rate for Payer: WPS Commercial |
$1,765.09
|
|
