|
PACK ADULT PUMP X-COATED FX 71875-01
|
Facility
|
IP
|
$6,658.00
|
|
| Hospital Charge Code |
2962887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,262.42 |
| Max. Negotiated Rate |
$6,125.36 |
| Rate for Payer: Aetna Commercial |
$5,992.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,725.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,528.74
|
| Rate for Payer: Cash Price |
$1,997.40
|
| Rate for Payer: Cigna Commercial |
$6,125.36
|
| Rate for Payer: Health EOS Commercial |
$5,925.62
|
| Rate for Payer: HFN Commercial |
$6,125.36
|
| Rate for Payer: Multiplan Commercial |
$5,326.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,994.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,125.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,262.42
|
| Rate for Payer: Quartz Commercial |
$3,994.80
|
| Rate for Payer: WEA Trust Commercial |
$3,661.90
|
| Rate for Payer: WPS Commercial |
$4,931.58
|
|
|
PACK ADULT PUMP X-COATED FX 71875-01
|
Facility
|
OP
|
$6,658.00
|
|
| Hospital Charge Code |
2962887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.24 |
| Max. Negotiated Rate |
$26,632.00 |
| Rate for Payer: Aetna Commercial |
$5,992.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,725.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,864.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,327.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,329.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,195.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,528.74
|
| Rate for Payer: Cash Price |
$1,997.40
|
| Rate for Payer: Cigna Commercial |
$6,125.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,725.82
|
| Rate for Payer: Health EOS Commercial |
$5,925.62
|
| Rate for Payer: HFN Commercial |
$6,125.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,993.50
|
| Rate for Payer: Multiplan Commercial |
$5,326.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,994.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,125.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,262.42
|
| Rate for Payer: Quartz Commercial |
$4,327.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,994.80
|
| Rate for Payer: The Alliance Commercial |
$26,632.00
|
| Rate for Payer: WEA Trust Commercial |
$3,661.90
|
| Rate for Payer: WPS Commercial |
$4,931.58
|
|
|
PACK BIRTHING ROOM
|
Facility
|
IP
|
$337.00
|
|
| Hospital Charge Code |
2963430
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$165.13 |
| Max. Negotiated Rate |
$310.04 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$202.20
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$202.20
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
PACK BIRTHING ROOM
|
Facility
|
OP
|
$337.00
|
|
| Hospital Charge Code |
2963430
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.36 |
| Max. Negotiated Rate |
$1,348.00 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Aetna Managed Medicare |
$94.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$219.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$168.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$161.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$188.59
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.75
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$202.20
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$219.05
|
| Rate for Payer: Quartz Medicare Advantage |
$202.20
|
| Rate for Payer: The Alliance Commercial |
$1,348.00
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
PACK CARDIOPLEGIA 027770201
|
Facility
|
IP
|
$1,691.00
|
|
| Hospital Charge Code |
2962886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$828.59 |
| Max. Negotiated Rate |
$1,555.72 |
| Rate for Payer: Aetna Commercial |
$1,521.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,454.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$896.23
|
| Rate for Payer: Cash Price |
$507.30
|
| Rate for Payer: Cigna Commercial |
$1,555.72
|
| Rate for Payer: Health EOS Commercial |
$1,504.99
|
| Rate for Payer: HFN Commercial |
$1,555.72
|
| Rate for Payer: Multiplan Commercial |
$1,352.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,014.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,555.72
|
| Rate for Payer: Quartz Beloit One Network |
$828.59
|
| Rate for Payer: Quartz Commercial |
$1,014.60
|
| Rate for Payer: WEA Trust Commercial |
$930.05
|
| Rate for Payer: WPS Commercial |
$1,252.52
|
|
|
PACK CARDIOPLEGIA 027770201
|
Facility
|
OP
|
$1,691.00
|
|
| Hospital Charge Code |
2962886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$473.48 |
| Max. Negotiated Rate |
$6,764.00 |
| Rate for Payer: Aetna Commercial |
$1,521.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,454.26
|
| Rate for Payer: Aetna Managed Medicare |
$473.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,099.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$845.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$811.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$896.23
|
| Rate for Payer: Cash Price |
$507.30
|
| Rate for Payer: Cigna Commercial |
$1,555.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$946.28
|
| Rate for Payer: Health EOS Commercial |
$1,504.99
|
| Rate for Payer: HFN Commercial |
$1,555.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,268.25
|
| Rate for Payer: Multiplan Commercial |
$1,352.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,014.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,555.72
|
| Rate for Payer: Quartz Beloit One Network |
$828.59
|
| Rate for Payer: Quartz Commercial |
$1,099.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,014.60
|
| Rate for Payer: The Alliance Commercial |
$6,764.00
|
| Rate for Payer: WEA Trust Commercial |
$930.05
|
| Rate for Payer: WPS Commercial |
$1,252.52
|
|
|
PACK CATARACT BASIC AS10572
|
Facility
|
IP
|
$4,344.00
|
|
| Hospital Charge Code |
2962933
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,128.56 |
| Max. Negotiated Rate |
$3,996.48 |
| Rate for Payer: Aetna Commercial |
$3,909.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,735.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,302.32
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Cigna Commercial |
$3,996.48
|
| Rate for Payer: Health EOS Commercial |
$3,866.16
|
| Rate for Payer: HFN Commercial |
$3,996.48
|
| Rate for Payer: Multiplan Commercial |
$3,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,996.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,128.56
|
| Rate for Payer: Quartz Commercial |
$2,606.40
|
| Rate for Payer: WEA Trust Commercial |
$2,389.20
|
| Rate for Payer: WPS Commercial |
$3,217.60
|
|
|
PACK CATARACT BASIC AS10572
|
Facility
|
OP
|
$4,344.00
|
|
| Hospital Charge Code |
2962933
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,216.32 |
| Max. Negotiated Rate |
$17,376.00 |
| Rate for Payer: Aetna Commercial |
$3,909.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,735.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,216.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,823.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,172.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,085.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,302.32
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Cigna Commercial |
$3,996.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,430.90
|
| Rate for Payer: Health EOS Commercial |
$3,866.16
|
| Rate for Payer: HFN Commercial |
$3,996.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,258.00
|
| Rate for Payer: Multiplan Commercial |
$3,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,996.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,128.56
|
| Rate for Payer: Quartz Commercial |
$2,823.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,606.40
|
| Rate for Payer: The Alliance Commercial |
$17,376.00
|
| Rate for Payer: WEA Trust Commercial |
$2,389.20
|
| Rate for Payer: WPS Commercial |
$3,217.60
|
|
|
PACK CATARACT FRIEDRICHS AS18176
|
Facility
|
IP
|
$3,969.00
|
|
| Hospital Charge Code |
5459618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,944.81 |
| Max. Negotiated Rate |
$3,651.48 |
| Rate for Payer: Aetna Commercial |
$3,572.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,413.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,103.57
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: Cigna Commercial |
$3,651.48
|
| Rate for Payer: Health EOS Commercial |
$3,532.41
|
| Rate for Payer: HFN Commercial |
$3,651.48
|
| Rate for Payer: Multiplan Commercial |
$3,175.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,381.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,944.81
|
| Rate for Payer: Quartz Commercial |
$2,381.40
|
| Rate for Payer: WEA Trust Commercial |
$2,182.95
|
| Rate for Payer: WPS Commercial |
$2,939.84
|
|
|
PACK CATARACT FRIEDRICHS AS18176
|
Facility
|
OP
|
$3,969.00
|
|
| Hospital Charge Code |
5459618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.32 |
| Max. Negotiated Rate |
$15,876.00 |
| Rate for Payer: Aetna Commercial |
$3,572.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,413.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,111.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,579.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,905.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,103.57
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: Cigna Commercial |
$3,651.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,221.05
|
| Rate for Payer: Health EOS Commercial |
$3,532.41
|
| Rate for Payer: HFN Commercial |
$3,651.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,976.75
|
| Rate for Payer: Multiplan Commercial |
$3,175.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,381.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,651.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,944.81
|
| Rate for Payer: Quartz Commercial |
$2,579.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,381.40
|
| Rate for Payer: The Alliance Commercial |
$15,876.00
|
| Rate for Payer: WEA Trust Commercial |
$2,182.95
|
| Rate for Payer: WPS Commercial |
$2,939.84
|
|
|
PACK CLOSUREFAST PROCEDURE CFP
|
Facility
|
OP
|
$1,637.00
|
|
| Hospital Charge Code |
4069310
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$458.36 |
| Max. Negotiated Rate |
$6,548.00 |
| Rate for Payer: Aetna Commercial |
$1,473.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,407.82
|
| Rate for Payer: Aetna Managed Medicare |
$458.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,064.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$818.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$785.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$867.61
|
| Rate for Payer: Cash Price |
$491.10
|
| Rate for Payer: Cigna Commercial |
$1,506.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$916.07
|
| Rate for Payer: Health EOS Commercial |
$1,456.93
|
| Rate for Payer: HFN Commercial |
$1,506.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,227.75
|
| Rate for Payer: Multiplan Commercial |
$1,309.60
|
| Rate for Payer: NAPHCARE Commercial |
$982.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,506.04
|
| Rate for Payer: Quartz Beloit One Network |
$802.13
|
| Rate for Payer: Quartz Commercial |
$1,064.05
|
| Rate for Payer: Quartz Medicare Advantage |
$982.20
|
| Rate for Payer: The Alliance Commercial |
$6,548.00
|
| Rate for Payer: WEA Trust Commercial |
$900.35
|
| Rate for Payer: WPS Commercial |
$1,212.53
|
|
|
PACK CLOSUREFAST PROCEDURE CFP
|
Facility
|
IP
|
$1,637.00
|
|
| Hospital Charge Code |
4069310
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$802.13 |
| Max. Negotiated Rate |
$1,506.04 |
| Rate for Payer: Aetna Commercial |
$1,473.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,407.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$867.61
|
| Rate for Payer: Cash Price |
$491.10
|
| Rate for Payer: Cigna Commercial |
$1,506.04
|
| Rate for Payer: Health EOS Commercial |
$1,456.93
|
| Rate for Payer: HFN Commercial |
$1,506.04
|
| Rate for Payer: Multiplan Commercial |
$1,309.60
|
| Rate for Payer: NAPHCARE Commercial |
$982.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,506.04
|
| Rate for Payer: Quartz Beloit One Network |
$802.13
|
| Rate for Payer: Quartz Commercial |
$982.20
|
| Rate for Payer: WEA Trust Commercial |
$900.35
|
| Rate for Payer: WPS Commercial |
$1,212.53
|
|
|
PACK CV HEART DRAPE CUSTOM DYNJ30558
|
Facility
|
IP
|
$5,767.00
|
|
| Hospital Charge Code |
2962889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,825.83 |
| Max. Negotiated Rate |
$5,305.64 |
| Rate for Payer: Aetna Commercial |
$5,190.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,959.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,056.51
|
| Rate for Payer: Cash Price |
$1,730.10
|
| Rate for Payer: Cigna Commercial |
$5,305.64
|
| Rate for Payer: Health EOS Commercial |
$5,132.63
|
| Rate for Payer: HFN Commercial |
$5,305.64
|
| Rate for Payer: Multiplan Commercial |
$4,613.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,460.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,305.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,825.83
|
| Rate for Payer: Quartz Commercial |
$3,460.20
|
| Rate for Payer: WEA Trust Commercial |
$3,171.85
|
| Rate for Payer: WPS Commercial |
$4,271.62
|
|
|
PACK CV HEART DRAPE CUSTOM DYNJ30558
|
Facility
|
OP
|
$5,767.00
|
|
| Hospital Charge Code |
2962889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,614.76 |
| Max. Negotiated Rate |
$23,068.00 |
| Rate for Payer: Aetna Commercial |
$5,190.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,959.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,614.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,748.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,883.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,768.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,056.51
|
| Rate for Payer: Cash Price |
$1,730.10
|
| Rate for Payer: Cigna Commercial |
$5,305.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,227.21
|
| Rate for Payer: Health EOS Commercial |
$5,132.63
|
| Rate for Payer: HFN Commercial |
$5,305.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,325.25
|
| Rate for Payer: Multiplan Commercial |
$4,613.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,460.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,305.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,825.83
|
| Rate for Payer: Quartz Commercial |
$3,748.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,460.20
|
| Rate for Payer: The Alliance Commercial |
$23,068.00
|
| Rate for Payer: WEA Trust Commercial |
$3,171.85
|
| Rate for Payer: WPS Commercial |
$4,271.62
|
|
|
PACK GENERAL ORTHOPEDIC 88411
|
Facility
|
OP
|
$484.00
|
|
| Hospital Charge Code |
2963230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$1,936.00 |
| Rate for Payer: Aetna Commercial |
$435.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.24
|
| Rate for Payer: Aetna Managed Medicare |
$135.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$314.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$242.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$232.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.52
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$445.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.85
|
| Rate for Payer: Health EOS Commercial |
$430.76
|
| Rate for Payer: HFN Commercial |
$445.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$363.00
|
| Rate for Payer: Multiplan Commercial |
$387.20
|
| Rate for Payer: NAPHCARE Commercial |
$290.40
|
| Rate for Payer: Preferred Network Access Commercial |
$445.28
|
| Rate for Payer: Quartz Beloit One Network |
$237.16
|
| Rate for Payer: Quartz Commercial |
$314.60
|
| Rate for Payer: Quartz Medicare Advantage |
$290.40
|
| Rate for Payer: The Alliance Commercial |
$1,936.00
|
| Rate for Payer: WEA Trust Commercial |
$266.20
|
| Rate for Payer: WPS Commercial |
$358.50
|
|
|
PACK GENERAL ORTHOPEDIC 88411
|
Facility
|
IP
|
$484.00
|
|
| Hospital Charge Code |
2963230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$237.16 |
| Max. Negotiated Rate |
$445.28 |
| Rate for Payer: Aetna Commercial |
$435.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.52
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$445.28
|
| Rate for Payer: Health EOS Commercial |
$430.76
|
| Rate for Payer: HFN Commercial |
$445.28
|
| Rate for Payer: Multiplan Commercial |
$387.20
|
| Rate for Payer: NAPHCARE Commercial |
$290.40
|
| Rate for Payer: Preferred Network Access Commercial |
$445.28
|
| Rate for Payer: Quartz Beloit One Network |
$237.16
|
| Rate for Payer: Quartz Commercial |
$290.40
|
| Rate for Payer: WEA Trust Commercial |
$266.20
|
| Rate for Payer: WPS Commercial |
$358.50
|
|
|
PACK HEAD AND NECK EENT 88716
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
2963812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.16 |
| Max. Negotiated Rate |
$1,788.00 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Aetna Managed Medicare |
$125.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.14
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.25
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$290.55
|
| Rate for Payer: Quartz Medicare Advantage |
$268.20
|
| Rate for Payer: The Alliance Commercial |
$1,788.00
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
PACK HEAD AND NECK EENT 88716
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
2963812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.03 |
| Max. Negotiated Rate |
$411.24 |
| Rate for Payer: Aetna Commercial |
$402.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$236.91
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$411.24
|
| Rate for Payer: Health EOS Commercial |
$397.83
|
| Rate for Payer: HFN Commercial |
$411.24
|
| Rate for Payer: Multiplan Commercial |
$357.60
|
| Rate for Payer: NAPHCARE Commercial |
$268.20
|
| Rate for Payer: Preferred Network Access Commercial |
$411.24
|
| Rate for Payer: Quartz Beloit One Network |
$219.03
|
| Rate for Payer: Quartz Commercial |
$268.20
|
| Rate for Payer: WEA Trust Commercial |
$245.85
|
| Rate for Payer: WPS Commercial |
$331.09
|
|
|
PACKING 1 STRIPS CURITY AMD 7833AMD
|
Facility
|
IP
|
$120.00
|
|
| Hospital Charge Code |
2969224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
PACKING 1 STRIPS CURITY AMD 7833AMD
|
Facility
|
OP
|
$120.00
|
|
| Hospital Charge Code |
2969224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: The Alliance Commercial |
$480.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
PACKING IODOFORM 1/2 X 5 YRDS
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2964050
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
PACKING IODOFORM 1/2 X 5 YRDS
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2964050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$25.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.16
|
| 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: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.00
|
| 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 |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$55.20
|
| Rate for Payer: The Alliance Commercial |
$368.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
PACKING IODOFORM 1/4 X 5 YRD 7831
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2963725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
PACKING IODOFORM 1/4 X 5 YRD 7831
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2963725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
PACKING NASAL 5.5cm ANTERIOR #551
|
Facility
|
IP
|
$719.00
|
|
| Hospital Charge Code |
2969617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.31 |
| Max. Negotiated Rate |
$661.48 |
| Rate for Payer: Aetna Commercial |
$647.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$618.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.07
|
| Rate for Payer: Cash Price |
$215.70
|
| Rate for Payer: Cigna Commercial |
$661.48
|
| Rate for Payer: Health EOS Commercial |
$639.91
|
| Rate for Payer: HFN Commercial |
$661.48
|
| Rate for Payer: Multiplan Commercial |
$575.20
|
| Rate for Payer: NAPHCARE Commercial |
$431.40
|
| Rate for Payer: Preferred Network Access Commercial |
$661.48
|
| Rate for Payer: Quartz Beloit One Network |
$352.31
|
| Rate for Payer: Quartz Commercial |
$431.40
|
| Rate for Payer: WEA Trust Commercial |
$395.45
|
| Rate for Payer: WPS Commercial |
$532.56
|
|
