|
NUT BUTRESS COMPRESSION
|
Facility
|
OP
|
$2,078.00
|
|
| Hospital Charge Code |
2966306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$605.11 |
| Max. Negotiated Rate |
$1,988.23 |
| Rate for Payer: Aetna Commercial |
$1,945.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,858.56
|
| Rate for Payer: Aetna Managed Medicare |
$605.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,404.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,080.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,037.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.39
|
| Rate for Payer: Cash Price |
$623.40
|
| Rate for Payer: Cigna Commercial |
$1,988.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,209.40
|
| Rate for Payer: Health EOS Commercial |
$1,923.40
|
| Rate for Payer: HFN Commercial |
$1,988.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,620.84
|
| Rate for Payer: Multiplan Commercial |
$1,728.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,296.67
|
| Rate for Payer: Preferred Network Access Commercial |
$1,988.23
|
| Rate for Payer: Quartz Beloit One Network |
$1,058.95
|
| Rate for Payer: Quartz Commercial |
$1,404.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,296.67
|
| Rate for Payer: The Alliance Commercial |
$1,080.56
|
| Rate for Payer: WEA Trust Commercial |
$1,188.62
|
| Rate for Payer: WPS Commercial |
$1,600.68
|
|
|
NUT BUTRESS COMPRESSION
|
Facility
|
IP
|
$2,078.00
|
|
| Hospital Charge Code |
2966306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,058.95 |
| Max. Negotiated Rate |
$1,988.23 |
| Rate for Payer: Aetna Commercial |
$1,945.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,858.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.39
|
| Rate for Payer: Cash Price |
$623.40
|
| Rate for Payer: Cigna Commercial |
$1,988.23
|
| Rate for Payer: Health EOS Commercial |
$1,923.40
|
| Rate for Payer: HFN Commercial |
$1,988.23
|
| Rate for Payer: Multiplan Commercial |
$1,728.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,988.23
|
| Rate for Payer: Quartz Beloit One Network |
$1,058.95
|
| Rate for Payer: Quartz Commercial |
$1,296.67
|
| Rate for Payer: WEA Trust Commercial |
$1,188.62
|
| Rate for Payer: WPS Commercial |
$1,600.68
|
|
|
NUT CONNECTING M6 HOFFMANN LIMB 4933-1-701
|
Facility
|
IP
|
$353.00
|
|
| Hospital Charge Code |
6001644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.89 |
| Max. Negotiated Rate |
$337.75 |
| Rate for Payer: Aetna Commercial |
$330.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.57
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cigna Commercial |
$337.75
|
| Rate for Payer: Health EOS Commercial |
$326.74
|
| Rate for Payer: HFN Commercial |
$337.75
|
| Rate for Payer: Multiplan Commercial |
$293.70
|
| Rate for Payer: Preferred Network Access Commercial |
$337.75
|
| Rate for Payer: Quartz Beloit One Network |
$179.89
|
| Rate for Payer: Quartz Commercial |
$220.27
|
| Rate for Payer: WEA Trust Commercial |
$201.92
|
| Rate for Payer: WPS Commercial |
$271.92
|
|
|
NUT CONNECTING M6 HOFFMANN LIMB 4933-1-701
|
Facility
|
OP
|
$353.00
|
|
| Hospital Charge Code |
6001644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.79 |
| Max. Negotiated Rate |
$337.75 |
| Rate for Payer: Aetna Commercial |
$330.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.72
|
| Rate for Payer: Aetna Managed Medicare |
$102.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$238.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$183.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.57
|
| Rate for Payer: Cash Price |
$105.90
|
| Rate for Payer: Cigna Commercial |
$337.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.45
|
| Rate for Payer: Health EOS Commercial |
$326.74
|
| Rate for Payer: HFN Commercial |
$337.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.34
|
| Rate for Payer: Multiplan Commercial |
$293.70
|
| Rate for Payer: NAPHCARE Commercial |
$220.27
|
| Rate for Payer: Preferred Network Access Commercial |
$337.75
|
| Rate for Payer: Quartz Beloit One Network |
$179.89
|
| Rate for Payer: Quartz Commercial |
$238.63
|
| Rate for Payer: Quartz Medicare Advantage |
$220.27
|
| Rate for Payer: The Alliance Commercial |
$183.56
|
| Rate for Payer: WEA Trust Commercial |
$201.92
|
| Rate for Payer: WPS Commercial |
$271.92
|
|
|
NUT SPRING-LOADED 393.43
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
5811624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.72 |
| Max. Negotiated Rate |
$574.08 |
| Rate for Payer: Aetna Commercial |
$561.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$536.64
|
| Rate for Payer: Aetna Managed Medicare |
$174.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$405.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$312.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$299.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$330.72
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$574.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$349.20
|
| Rate for Payer: Health EOS Commercial |
$555.36
|
| Rate for Payer: HFN Commercial |
$574.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$468.00
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: NAPHCARE Commercial |
$374.40
|
| Rate for Payer: Preferred Network Access Commercial |
$574.08
|
| Rate for Payer: Quartz Beloit One Network |
$305.76
|
| Rate for Payer: Quartz Commercial |
$405.60
|
| Rate for Payer: Quartz Medicare Advantage |
$374.40
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$343.20
|
| Rate for Payer: WPS Commercial |
$462.18
|
|
|
NUT SPRING-LOADED 393.43
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
5811624
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$305.76 |
| Max. Negotiated Rate |
$574.08 |
| Rate for Payer: Aetna Commercial |
$561.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$536.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$330.72
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$574.08
|
| Rate for Payer: Health EOS Commercial |
$555.36
|
| Rate for Payer: HFN Commercial |
$574.08
|
| Rate for Payer: Multiplan Commercial |
$499.20
|
| Rate for Payer: Preferred Network Access Commercial |
$574.08
|
| Rate for Payer: Quartz Beloit One Network |
$305.76
|
| Rate for Payer: Quartz Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$343.20
|
| Rate for Payer: WPS Commercial |
$462.18
|
|
|
O2 Hood with Blender/Humidifier - Daily Charges
|
Facility
|
IP
|
$1,007.00
|
|
| Hospital Charge Code |
3003960
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$628.37
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
O2 Hood with Blender/Humidifier - Daily Charges
|
Facility
|
OP
|
$1,007.00
|
|
| Hospital Charge Code |
3003960
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$293.24 |
| Max. Negotiated Rate |
$963.50 |
| Rate for Payer: Aetna Commercial |
$942.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.66
|
| Rate for Payer: Aetna Managed Medicare |
$293.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.06
|
| Rate for Payer: Cash Price |
$302.10
|
| Rate for Payer: Cigna Commercial |
$963.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.07
|
| Rate for Payer: Health EOS Commercial |
$932.08
|
| Rate for Payer: HFN Commercial |
$963.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$785.46
|
| Rate for Payer: Multiplan Commercial |
$837.82
|
| Rate for Payer: NAPHCARE Commercial |
$628.37
|
| Rate for Payer: Preferred Network Access Commercial |
$963.50
|
| Rate for Payer: Quartz Beloit One Network |
$513.17
|
| Rate for Payer: Quartz Commercial |
$680.73
|
| Rate for Payer: Quartz Medicare Advantage |
$628.37
|
| Rate for Payer: The Alliance Commercial |
$523.64
|
| Rate for Payer: United Healthcare PPO |
$785.46
|
| Rate for Payer: WEA Trust Commercial |
$576.00
|
| Rate for Payer: WPS Commercial |
$775.69
|
|
|
O2 Hood with Blender/Humidifier - Nursery Daily Charges
|
Facility
|
OP
|
$930.00
|
|
| Hospital Charge Code |
3003952
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$270.82 |
| Max. Negotiated Rate |
$889.82 |
| Rate for Payer: Aetna Commercial |
$870.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$831.79
|
| Rate for Payer: Aetna Managed Medicare |
$270.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$628.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$483.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$464.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$512.62
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$889.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.26
|
| Rate for Payer: Health EOS Commercial |
$860.81
|
| Rate for Payer: HFN Commercial |
$889.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$725.40
|
| Rate for Payer: Multiplan Commercial |
$773.76
|
| Rate for Payer: NAPHCARE Commercial |
$580.32
|
| Rate for Payer: Preferred Network Access Commercial |
$889.82
|
| Rate for Payer: Quartz Beloit One Network |
$473.93
|
| Rate for Payer: Quartz Commercial |
$628.68
|
| Rate for Payer: Quartz Medicare Advantage |
$580.32
|
| Rate for Payer: The Alliance Commercial |
$483.60
|
| Rate for Payer: United Healthcare PPO |
$725.40
|
| Rate for Payer: WEA Trust Commercial |
$531.96
|
| Rate for Payer: WPS Commercial |
$716.38
|
|
|
O2 Hood with Blender/Humidifier - Nursery Daily Charges
|
Facility
|
IP
|
$930.00
|
|
| Hospital Charge Code |
3003952
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$473.93 |
| Max. Negotiated Rate |
$889.82 |
| Rate for Payer: Aetna Commercial |
$870.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$831.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$512.62
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$889.82
|
| Rate for Payer: Health EOS Commercial |
$860.81
|
| Rate for Payer: HFN Commercial |
$889.82
|
| Rate for Payer: Multiplan Commercial |
$773.76
|
| Rate for Payer: Preferred Network Access Commercial |
$889.82
|
| Rate for Payer: Quartz Beloit One Network |
$473.93
|
| Rate for Payer: Quartz Commercial |
$580.32
|
| Rate for Payer: WEA Trust Commercial |
$531.96
|
| Rate for Payer: WPS Commercial |
$716.38
|
|
|
OAE Limited
|
Facility
|
OP
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$205.17 |
| Max. Negotiated Rate |
$908.96 |
| Rate for Payer: Aetna Commercial |
$384.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.60
|
| Rate for Payer: Aetna Managed Medicare |
$227.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$277.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$213.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$205.17
|
| Rate for Payer: Anthem Medicare Advantage |
$227.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$227.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$227.24
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$393.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$227.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$227.24
|
| Rate for Payer: Health EOS Commercial |
$380.42
|
| Rate for Payer: HFN Commercial |
$393.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$227.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$227.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$227.24
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: NAPHCARE Commercial |
$340.86
|
| Rate for Payer: Preferred Network Access Commercial |
$393.24
|
| Rate for Payer: Quartz Beloit One Network |
$209.45
|
| Rate for Payer: Quartz Commercial |
$277.84
|
| Rate for Payer: Quartz Medicare Advantage |
$227.24
|
| Rate for Payer: The Alliance Commercial |
$908.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$227.24
|
| Rate for Payer: United Healthcare PPO |
$320.58
|
| Rate for Payer: WEA Trust Commercial |
$235.09
|
| Rate for Payer: Wellcare Medicare |
$227.24
|
| Rate for Payer: WPS Commercial |
$316.59
|
|
|
OAE Limited
|
Professional
|
Both
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$22.03 |
| Max. Negotiated Rate |
$406.07 |
| Rate for Payer: Aetna Commercial |
$406.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.60
|
| Rate for Payer: Aetna Managed Medicare |
$22.03
|
| Rate for Payer: Anthem Medicare Advantage |
$22.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.03
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$406.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.03
|
| Rate for Payer: Health EOS Commercial |
$388.97
|
| Rate for Payer: HFN Commercial |
$406.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$79.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.03
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: NAPHCARE Commercial |
$33.04
|
| Rate for Payer: Preferred Network Access Commercial |
$406.07
|
| Rate for Payer: Quartz Beloit One Network |
$188.07
|
| Rate for Payer: Quartz Commercial |
$243.64
|
| Rate for Payer: Quartz Medicare Advantage |
$22.03
|
| Rate for Payer: The Alliance Commercial |
$55.07
|
| Rate for Payer: United Healthcare Medicaid |
$59.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.03
|
| Rate for Payer: WEA Trust Commercial |
$235.09
|
| Rate for Payer: WPS Commercial |
$88.11
|
|
|
OAE Limited
|
Facility
|
IP
|
$411.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
3203497
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$209.45 |
| Max. Negotiated Rate |
$393.24 |
| Rate for Payer: Aetna Commercial |
$384.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.54
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$393.24
|
| Rate for Payer: Health EOS Commercial |
$380.42
|
| Rate for Payer: HFN Commercial |
$393.24
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: Preferred Network Access Commercial |
$393.24
|
| Rate for Payer: Quartz Beloit One Network |
$209.45
|
| Rate for Payer: Quartz Commercial |
$256.46
|
| Rate for Payer: WEA Trust Commercial |
$235.09
|
| Rate for Payer: WPS Commercial |
$316.59
|
|
|
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 |
$9.61 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.06
|
| Rate for Payer: Health EOS Commercial |
$19.87
|
| Rate for Payer: HFN Commercial |
$20.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$20.75
|
| Rate for Payer: Quartz Beloit One Network |
$9.61
|
| Rate for Payer: Quartz Commercial |
$12.45
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$32.66
|
|
|
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 |
$10.48 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.48
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$14.20
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$32.66
|
|
|
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 |
$10.70 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$13.10
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
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 |
$55.04 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$67.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
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 |
$12.34 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.91
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$73.01
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
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 |
$9.33 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$106.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.33
|
| Rate for Payer: Health EOS Commercial |
$102.21
|
| Rate for Payer: HFN Commercial |
$106.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$106.70
|
| Rate for Payer: Quartz Beloit One Network |
$49.42
|
| Rate for Payer: Quartz Commercial |
$64.02
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$23.32
|
|
|
OBESITY
|
Facility
|
OP
|
$87.79
|
|
|
Service Code
|
EAPG 00695
|
| Min. Negotiated Rate |
$84.41 |
| Max. Negotiated Rate |
$87.79 |
| Rate for Payer: Anthem Medicaid |
$84.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$84.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.41
|
| Rate for Payer: Dean Health Medicaid |
$84.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$84.41
|
| Rate for Payer: Managed Health Services Medicaid |
$87.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$84.41
|
| Rate for Payer: United Healthcare Medicaid |
$84.41
|
|
|
OBSERVATION
|
Facility
|
OP
|
$20.96
|
|
|
Service Code
|
EAPG 00450
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$20.96 |
| Rate for Payer: Anthem Medicaid |
$20.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.16
|
| Rate for Payer: Dean Health Medicaid |
$20.16
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20.16
|
| Rate for Payer: Managed Health Services Medicaid |
$20.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20.16
|
| Rate for Payer: United Healthcare Medicaid |
$20.16
|
|
|
Observation 1st Hour Direct Admit
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3298772
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
Observation 1st Hour Direct Admit
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3298772
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$7,271.68 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$626.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,271.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,271.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,958.16
|
| Rate for Payer: Anthem Medicare Advantage |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$626.74
|
| 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 |
$88.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$626.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$626.74
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$626.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$626.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$626.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$626.74
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$940.10
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$626.74
|
| Rate for Payer: The Alliance Commercial |
$2,506.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$626.74
|
| Rate for Payer: United Healthcare PPO |
$2,701.92
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: Wellcare Medicare |
$626.74
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
OBSESSIVE COMPULSIVE DISORDERS
|
Facility
|
IP
|
$6,313.18
|
|
|
Service Code
|
APR-DRG 7622
|
| Min. Negotiated Rate |
$5,607.76 |
| Max. Negotiated Rate |
$6,313.18 |
| Rate for Payer: Anthem Medicaid |
$6,045.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,045.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,045.22
|
| Rate for Payer: Dean Health Medicaid |
$6,045.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,607.76
|
| Rate for Payer: Managed Health Services Medicaid |
$6,313.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,045.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,045.22
|
| Rate for Payer: United Healthcare Medicaid |
$6,045.22
|
|
|
OBSESSIVE COMPULSIVE DISORDERS
|
Facility
|
IP
|
$10,083.56
|
|
|
Service Code
|
APR-DRG 7623
|
| Min. Negotiated Rate |
$8,956.84 |
| Max. Negotiated Rate |
$10,083.56 |
| Rate for Payer: Anthem Medicaid |
$9,655.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,655.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,655.56
|
| Rate for Payer: Dean Health Medicaid |
$9,655.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,956.84
|
| Rate for Payer: Managed Health Services Medicaid |
$10,083.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,655.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,655.56
|
| Rate for Payer: United Healthcare Medicaid |
$9,655.56
|
|
