|
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
|
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
|
$23.37
|
|
|
Service Code
|
EAPG 00695
|
| Min. Negotiated Rate |
$22.47 |
| Max. Negotiated Rate |
$23.37 |
| Rate for Payer: Anthem Medicaid |
$22.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.47
|
| Rate for Payer: Dean Health Medicaid |
$22.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22.47
|
| Rate for Payer: Managed Health Services Medicaid |
$23.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.47
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.47
|
| Rate for Payer: United Healthcare Medicaid |
$22.47
|
|
|
OBSERVATION
|
Facility
|
OP
|
$185.36
|
|
|
Service Code
|
EAPG 00450
|
| Min. Negotiated Rate |
$178.23 |
| Max. Negotiated Rate |
$185.36 |
| Rate for Payer: Anthem Medicaid |
$178.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$178.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$178.23
|
| Rate for Payer: Dean Health Medicaid |
$178.23
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$178.23
|
| Rate for Payer: Managed Health Services Medicaid |
$185.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.23
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$178.23
|
| Rate for Payer: United Healthcare Medicaid |
$178.23
|
|
|
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
|
$5,348.67
|
|
|
Service Code
|
APR-DRG 7621
|
| Min. Negotiated Rate |
$4,751.02 |
| Max. Negotiated Rate |
$5,348.67 |
| Rate for Payer: Anthem Medicaid |
$5,121.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,121.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,121.65
|
| Rate for Payer: Dean Health Medicaid |
$5,121.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,751.02
|
| Rate for Payer: Managed Health Services Medicaid |
$5,348.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,121.65
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,121.65
|
| Rate for Payer: United Healthcare Medicaid |
$5,121.65
|
|
|
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
|
$11,661.85
|
|
|
Service Code
|
APR-DRG 7624
|
| Min. Negotiated Rate |
$10,358.78 |
| Max. Negotiated Rate |
$11,661.85 |
| Rate for Payer: Anthem Medicaid |
$11,166.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11,166.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11,166.87
|
| Rate for Payer: Dean Health Medicaid |
$11,166.87
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,358.78
|
| Rate for Payer: Managed Health Services Medicaid |
$11,661.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,166.87
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11,166.87
|
| Rate for Payer: United Healthcare Medicaid |
$11,166.87
|
|
|
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
|
|
|
OBSTETRICAL PROCEDURES
|
Facility
|
OP
|
$383.51
|
|
|
Service Code
|
EAPG 00205
|
| Min. Negotiated Rate |
$368.76 |
| Max. Negotiated Rate |
$383.51 |
| Rate for Payer: Anthem Medicaid |
$368.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$368.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$368.76
|
| Rate for Payer: Dean Health Medicaid |
$368.76
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$368.76
|
| Rate for Payer: Managed Health Services Medicaid |
$383.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$368.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$368.76
|
| Rate for Payer: United Healthcare Medicaid |
$368.76
|
|
|
OBSTETRICAL ULTRASOUND
|
Facility
|
OP
|
$21.56
|
|
|
Service Code
|
EAPG 00470
|
| Min. Negotiated Rate |
$20.73 |
| Max. Negotiated Rate |
$21.56 |
| Rate for Payer: Anthem Medicaid |
$20.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.73
|
| Rate for Payer: Dean Health Medicaid |
$20.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20.73
|
| Rate for Payer: Managed Health Services Medicaid |
$21.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.73
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20.73
|
| Rate for Payer: United Healthcare Medicaid |
$20.73
|
|
|
Obstetric Panel
|
Professional
|
Both
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.72 |
| Max. Negotiated Rate |
$1,022.58 |
| Rate for Payer: Aetna Commercial |
$1,022.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.70
|
| Rate for Payer: Aetna Managed Medicare |
$49.72
|
| Rate for Payer: Anthem Medicare Advantage |
$49.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.72
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$1,022.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$538.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.72
|
| Rate for Payer: Health EOS Commercial |
$979.52
|
| Rate for Payer: HFN Commercial |
$1,022.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$861.12
|
| Rate for Payer: NAPHCARE Commercial |
$74.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,022.58
|
| Rate for Payer: Quartz Beloit One Network |
$473.62
|
| Rate for Payer: Quartz Commercial |
$613.55
|
| Rate for Payer: Quartz Medicare Advantage |
$49.72
|
| Rate for Payer: The Alliance Commercial |
$196.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.72
|
| Rate for Payer: WEA Trust Commercial |
$592.02
|
| Rate for Payer: WPS Commercial |
$218.78
|
|
|
Obstetric Panel
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.72 |
| Max. Negotiated Rate |
$990.29 |
| Rate for Payer: Aetna Commercial |
$968.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.70
|
| Rate for Payer: Aetna Managed Medicare |
$49.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$186.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.54
|
| Rate for Payer: Anthem Medicare Advantage |
$49.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$570.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.72
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$990.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$602.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.72
|
| Rate for Payer: Health EOS Commercial |
$958.00
|
| Rate for Payer: HFN Commercial |
$990.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$861.12
|
| Rate for Payer: NAPHCARE Commercial |
$74.58
|
| Rate for Payer: Preferred Network Access Commercial |
$990.29
|
| Rate for Payer: Quartz Beloit One Network |
$527.44
|
| Rate for Payer: Quartz Commercial |
$699.66
|
| Rate for Payer: Quartz Medicare Advantage |
$49.72
|
| Rate for Payer: The Alliance Commercial |
$198.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.72
|
| Rate for Payer: United Healthcare PPO |
$807.30
|
| Rate for Payer: WEA Trust Commercial |
$592.02
|
| Rate for Payer: Wellcare Medicare |
$49.72
|
| Rate for Payer: WPS Commercial |
$797.26
|
|
|
Obstetric Panel
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
CPT 80055
|
| Hospital Charge Code |
1114868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$527.44 |
| Max. Negotiated Rate |
$990.29 |
| Rate for Payer: Aetna Commercial |
$968.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$570.49
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$990.29
|
| Rate for Payer: Health EOS Commercial |
$958.00
|
| Rate for Payer: HFN Commercial |
$990.29
|
| Rate for Payer: Multiplan Commercial |
$861.12
|
| Rate for Payer: Preferred Network Access Commercial |
$990.29
|
| Rate for Payer: Quartz Beloit One Network |
$527.44
|
| Rate for Payer: Quartz Commercial |
$645.84
|
| Rate for Payer: WEA Trust Commercial |
$592.02
|
| Rate for Payer: WPS Commercial |
$797.26
|
|
|
Obtaining Screen Pap Smear Q0091
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS Q0091
|
| Hospital Charge Code |
3157531
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$151.48 |
| Rate for Payer: Aetna Commercial |
$69.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.49
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$69.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.49
|
| Rate for Payer: Health EOS Commercial |
$66.25
|
| Rate for Payer: HFN Commercial |
$69.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$151.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.49
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$23.23
|
| Rate for Payer: Preferred Network Access Commercial |
$69.16
|
| Rate for Payer: Quartz Beloit One Network |
$32.03
|
| Rate for Payer: Quartz Commercial |
$41.50
|
| Rate for Payer: Quartz Medicare Advantage |
$15.49
|
| Rate for Payer: The Alliance Commercial |
$42.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.49
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$27.10
|
|
|
OBTURATOR FLEXIBLE AR-2275
|
Facility
|
IP
|
$2,383.00
|
|
| Hospital Charge Code |
5591320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,214.38 |
| Max. Negotiated Rate |
$2,280.05 |
| Rate for Payer: Aetna Commercial |
$2,230.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,131.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,313.51
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,280.05
|
| Rate for Payer: Health EOS Commercial |
$2,205.70
|
| Rate for Payer: HFN Commercial |
$2,280.05
|
| Rate for Payer: Multiplan Commercial |
$1,982.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,280.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.38
|
| Rate for Payer: Quartz Commercial |
$1,486.99
|
| Rate for Payer: WEA Trust Commercial |
$1,363.08
|
| Rate for Payer: WPS Commercial |
$1,835.62
|
|
|
OBTURATOR FLEXIBLE AR-2275
|
Facility
|
OP
|
$2,383.00
|
|
| Hospital Charge Code |
5591320
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$693.93 |
| Max. Negotiated Rate |
$2,280.05 |
| Rate for Payer: Aetna Commercial |
$2,230.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,131.36
|
| Rate for Payer: Aetna Managed Medicare |
$693.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,610.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,239.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,189.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,313.51
|
| Rate for Payer: Cash Price |
$714.90
|
| Rate for Payer: Cigna Commercial |
$2,280.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,386.91
|
| Rate for Payer: Health EOS Commercial |
$2,205.70
|
| Rate for Payer: HFN Commercial |
$2,280.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,858.74
|
| Rate for Payer: Multiplan Commercial |
$1,982.66
|
| Rate for Payer: NAPHCARE Commercial |
$1,486.99
|
| Rate for Payer: Preferred Network Access Commercial |
$2,280.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.38
|
| Rate for Payer: Quartz Commercial |
$1,610.91
|
| Rate for Payer: Quartz Medicare Advantage |
$1,486.99
|
| Rate for Payer: The Alliance Commercial |
$1,239.16
|
| Rate for Payer: WEA Trust Commercial |
$1,363.08
|
| Rate for Payer: WPS Commercial |
$1,835.62
|
|
|
OB Ultrasound-Simple - Individual Charges
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
3003920
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$848.64 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Aetna Managed Medicare |
$110.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$848.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$716.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$681.20
|
| Rate for Payer: Anthem Medicare Advantage |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.02
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$110.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$110.02
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$409.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$110.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$110.02
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: NAPHCARE Commercial |
$165.03
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$308.26
|
| Rate for Payer: Quartz Medicare Advantage |
$110.02
|
| Rate for Payer: The Alliance Commercial |
$440.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.02
|
| Rate for Payer: United Healthcare PPO |
$596.96
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: Wellcare Medicare |
$110.02
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
OB Ultrasound-Simple - Individual Charges
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
CPT 76815
|
| Hospital Charge Code |
3003920
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$284.54
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
OB Urine Protein
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$16.85
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
OB Urine Protein
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$7.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.71
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.06
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$16.85
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$18.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$14.04
|
| Rate for Payer: United Healthcare PPO |
$21.06
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
OB Urine Protein
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
CPT 81099
|
| Hospital Charge Code |
5184711
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.36 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.85
|
| Rate for Payer: Health EOS Commercial |
$25.55
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$12.36
|
| Rate for Payer: Quartz Commercial |
$16.01
|
| Rate for Payer: The Alliance Commercial |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
OB US, Limited, Fetus (S) 7681526
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 76815 26
|
| Hospital Charge Code |
4221354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.63 |
| Max. Negotiated Rate |
$165.98 |
| Rate for Payer: Aetna Commercial |
$165.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$30.63
|
| Rate for Payer: Anthem Medicare Advantage |
$30.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.63
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$165.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.63
|
| Rate for Payer: Health EOS Commercial |
$159.00
|
| Rate for Payer: HFN Commercial |
$165.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.63
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$45.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.98
|
| Rate for Payer: Quartz Beloit One Network |
$76.88
|
| Rate for Payer: Quartz Commercial |
$99.59
|
| Rate for Payer: Quartz Medicare Advantage |
$30.63
|
| Rate for Payer: The Alliance Commercial |
$116.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.63
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$153.14
|
|
|
Occ Bld Stl, Imm
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
979904
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$144.25 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Aetna Managed Medicare |
$16.56
|
| Rate for Payer: Anthem Medicare Advantage |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$144.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$138.17
|
| Rate for Payer: HFN Commercial |
$144.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: NAPHCARE Commercial |
$24.84
|
| Rate for Payer: Preferred Network Access Commercial |
$144.25
|
| Rate for Payer: Quartz Beloit One Network |
$66.81
|
| Rate for Payer: Quartz Commercial |
$86.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.56
|
| Rate for Payer: The Alliance Commercial |
$65.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.56
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: WPS Commercial |
$72.85
|
|
