|
APPLICATOR MINI COTTON TIPPED
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
2970890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
APPLICATOR MINI COTTON TIPPED
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
2970890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
APPLICATOR MYCROMIST EXTENDED TIP INTEGRA 15CM 205115
|
Facility
|
IP
|
$2,252.27
|
|
| Hospital Charge Code |
6246154
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,147.76 |
| Max. Negotiated Rate |
$2,154.97 |
| Rate for Payer: Aetna Commercial |
$2,108.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,014.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,241.45
|
| Rate for Payer: Cash Price |
$675.68
|
| Rate for Payer: Cigna Commercial |
$2,154.97
|
| Rate for Payer: Health EOS Commercial |
$2,084.70
|
| Rate for Payer: HFN Commercial |
$2,154.97
|
| Rate for Payer: Multiplan Commercial |
$1,873.89
|
| Rate for Payer: Preferred Network Access Commercial |
$2,154.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,147.76
|
| Rate for Payer: Quartz Commercial |
$1,405.42
|
| Rate for Payer: WEA Trust Commercial |
$1,288.30
|
| Rate for Payer: WPS Commercial |
$1,734.92
|
|
|
APPLICATOR MYCROMIST EXTENDED TIP INTEGRA 15CM 205115
|
Facility
|
OP
|
$2,252.27
|
|
| Hospital Charge Code |
6246154
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$655.86 |
| Max. Negotiated Rate |
$2,154.97 |
| Rate for Payer: Aetna Commercial |
$2,108.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,014.43
|
| Rate for Payer: Aetna Managed Medicare |
$655.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,522.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,171.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,124.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,241.45
|
| Rate for Payer: Cash Price |
$675.68
|
| Rate for Payer: Cigna Commercial |
$2,154.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,310.82
|
| Rate for Payer: Health EOS Commercial |
$2,084.70
|
| Rate for Payer: HFN Commercial |
$2,154.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,756.77
|
| Rate for Payer: Multiplan Commercial |
$1,873.89
|
| Rate for Payer: NAPHCARE Commercial |
$1,405.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,154.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,147.76
|
| Rate for Payer: Quartz Commercial |
$1,522.53
|
| Rate for Payer: Quartz Medicare Advantage |
$1,405.42
|
| Rate for Payer: The Alliance Commercial |
$1,171.18
|
| Rate for Payer: WEA Trust Commercial |
$1,288.30
|
| Rate for Payer: WPS Commercial |
$1,734.92
|
|
|
APPLICATOR MYCROMIST INTEGRA 14CM 205000DS
|
Facility
|
IP
|
$2,176.15
|
|
| Hospital Charge Code |
6246151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,108.97 |
| Max. Negotiated Rate |
$2,082.14 |
| Rate for Payer: Aetna Commercial |
$2,036.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,946.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,199.49
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cigna Commercial |
$2,082.14
|
| Rate for Payer: Health EOS Commercial |
$2,014.24
|
| Rate for Payer: HFN Commercial |
$2,082.14
|
| Rate for Payer: Multiplan Commercial |
$1,810.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,082.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,108.97
|
| Rate for Payer: Quartz Commercial |
$1,357.92
|
| Rate for Payer: WEA Trust Commercial |
$1,244.76
|
| Rate for Payer: WPS Commercial |
$1,676.29
|
|
|
APPLICATOR MYCROMIST INTEGRA 14CM 205000DS
|
Facility
|
OP
|
$2,176.15
|
|
| Hospital Charge Code |
6246151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$633.69 |
| Max. Negotiated Rate |
$2,082.14 |
| Rate for Payer: Aetna Commercial |
$2,036.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,946.35
|
| Rate for Payer: Aetna Managed Medicare |
$633.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,471.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,131.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,086.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,199.49
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cigna Commercial |
$2,082.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,266.52
|
| Rate for Payer: Health EOS Commercial |
$2,014.24
|
| Rate for Payer: HFN Commercial |
$2,082.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,697.40
|
| Rate for Payer: Multiplan Commercial |
$1,810.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,357.92
|
| Rate for Payer: Preferred Network Access Commercial |
$2,082.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,108.97
|
| Rate for Payer: Quartz Commercial |
$1,471.08
|
| Rate for Payer: Quartz Medicare Advantage |
$1,357.92
|
| Rate for Payer: The Alliance Commercial |
$1,131.60
|
| Rate for Payer: WEA Trust Commercial |
$1,244.76
|
| Rate for Payer: WPS Commercial |
$1,676.29
|
|
|
APPLIER LIGACLIP MULTI CLIP LARGE DISP MCL20
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
4519328
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.02 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$586.56
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
APPLIER LIGACLIP MULTI CLIP LARGE DISP MCL20
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
4519328
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$273.73 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Aetna Managed Medicare |
$273.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.08
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.20
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: NAPHCARE Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$635.44
|
| Rate for Payer: Quartz Medicare Advantage |
$586.56
|
| Rate for Payer: The Alliance Commercial |
$488.80
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
APPLIER LIGACLIP MULTI CLIP MED DISP MCM20/MCM30
|
Facility
|
IP
|
$940.00
|
|
| Hospital Charge Code |
3591514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.02 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$586.56
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
APPLIER LIGACLIP MULTI CLIP MED DISP MCM20/MCM30
|
Facility
|
OP
|
$940.00
|
|
| Hospital Charge Code |
3591514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$273.73 |
| Max. Negotiated Rate |
$899.39 |
| Rate for Payer: Aetna Commercial |
$879.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$840.74
|
| Rate for Payer: Aetna Managed Medicare |
$273.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$635.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$488.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$469.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$518.13
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$899.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.08
|
| Rate for Payer: Health EOS Commercial |
$870.06
|
| Rate for Payer: HFN Commercial |
$899.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$733.20
|
| Rate for Payer: Multiplan Commercial |
$782.08
|
| Rate for Payer: NAPHCARE Commercial |
$586.56
|
| Rate for Payer: Preferred Network Access Commercial |
$899.39
|
| Rate for Payer: Quartz Beloit One Network |
$479.02
|
| Rate for Payer: Quartz Commercial |
$635.44
|
| Rate for Payer: Quartz Medicare Advantage |
$586.56
|
| Rate for Payer: The Alliance Commercial |
$488.80
|
| Rate for Payer: WEA Trust Commercial |
$537.68
|
| Rate for Payer: WPS Commercial |
$724.08
|
|
|
APPLIER LIGACLIP MULTI CLIP SMALL DISP MCS20
|
Facility
|
OP
|
$899.00
|
|
| Hospital Charge Code |
5240776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.79 |
| Max. Negotiated Rate |
$860.16 |
| Rate for Payer: Aetna Commercial |
$841.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.07
|
| Rate for Payer: Aetna Managed Medicare |
$261.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$607.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$467.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$448.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.53
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$860.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$523.22
|
| Rate for Payer: Health EOS Commercial |
$832.11
|
| Rate for Payer: HFN Commercial |
$860.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$701.22
|
| Rate for Payer: Multiplan Commercial |
$747.97
|
| Rate for Payer: NAPHCARE Commercial |
$560.98
|
| Rate for Payer: Preferred Network Access Commercial |
$860.16
|
| Rate for Payer: Quartz Beloit One Network |
$458.13
|
| Rate for Payer: Quartz Commercial |
$607.72
|
| Rate for Payer: Quartz Medicare Advantage |
$560.98
|
| Rate for Payer: The Alliance Commercial |
$467.48
|
| Rate for Payer: WEA Trust Commercial |
$514.23
|
| Rate for Payer: WPS Commercial |
$692.50
|
|
|
APPLIER LIGACLIP MULTI CLIP SMALL DISP MCS20
|
Facility
|
IP
|
$899.00
|
|
| Hospital Charge Code |
5240776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$458.13 |
| Max. Negotiated Rate |
$860.16 |
| Rate for Payer: Aetna Commercial |
$841.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.53
|
| Rate for Payer: Cash Price |
$269.70
|
| Rate for Payer: Cigna Commercial |
$860.16
|
| Rate for Payer: Health EOS Commercial |
$832.11
|
| Rate for Payer: HFN Commercial |
$860.16
|
| Rate for Payer: Multiplan Commercial |
$747.97
|
| Rate for Payer: Preferred Network Access Commercial |
$860.16
|
| Rate for Payer: Quartz Beloit One Network |
$458.13
|
| Rate for Payer: Quartz Commercial |
$560.98
|
| Rate for Payer: WEA Trust Commercial |
$514.23
|
| Rate for Payer: WPS Commercial |
$692.50
|
|
|
APPL ON-BODY INJECTOR FOR TIMED SUBQ INJECTION 96377
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 96377
|
| Hospital Charge Code |
6182584
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$116.58 |
| Rate for Payer: Aetna Commercial |
$116.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$18.99
|
| Rate for Payer: Anthem Medicare Advantage |
$18.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.99
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$116.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.99
|
| Rate for Payer: Health EOS Commercial |
$111.68
|
| Rate for Payer: HFN Commercial |
$116.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$28.49
|
| Rate for Payer: Preferred Network Access Commercial |
$116.58
|
| Rate for Payer: Quartz Beloit One Network |
$54.00
|
| Rate for Payer: Quartz Commercial |
$69.95
|
| Rate for Payer: Quartz Medicare Advantage |
$18.99
|
| Rate for Payer: The Alliance Commercial |
$47.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.99
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$75.96
|
|
|
APPLY FINGER CAST 29086
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 29086
|
| Hospital Charge Code |
3014292
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.93 |
| Max. Negotiated Rate |
$205.50 |
| Rate for Payer: Aetna Commercial |
$202.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$45.67
|
| Rate for Payer: Anthem Medicare Advantage |
$45.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.67
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$202.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.67
|
| Rate for Payer: Health EOS Commercial |
$194.01
|
| Rate for Payer: HFN Commercial |
$202.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.67
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$68.50
|
| Rate for Payer: Preferred Network Access Commercial |
$202.54
|
| Rate for Payer: Quartz Beloit One Network |
$93.81
|
| Rate for Payer: Quartz Commercial |
$121.52
|
| Rate for Payer: Quartz Medicare Advantage |
$45.67
|
| Rate for Payer: The Alliance Commercial |
$194.08
|
| Rate for Payer: United Healthcare Medicaid |
$26.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.67
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$205.50
|
|
|
Apply Forearm Splint, Dynamic 29126
|
Professional
|
Both
|
$329.00
|
|
|
Service Code
|
CPT 29126
|
| Hospital Charge Code |
4590636
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.49 |
| Max. Negotiated Rate |
$325.05 |
| Rate for Payer: Aetna Commercial |
$325.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$294.26
|
| Rate for Payer: Aetna Managed Medicare |
$44.19
|
| Rate for Payer: Anthem Medicare Advantage |
$44.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$44.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$44.19
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cigna Commercial |
$325.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.19
|
| Rate for Payer: Health EOS Commercial |
$311.37
|
| Rate for Payer: HFN Commercial |
$325.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$44.19
|
| Rate for Payer: Multiplan Commercial |
$273.73
|
| Rate for Payer: NAPHCARE Commercial |
$66.28
|
| Rate for Payer: Preferred Network Access Commercial |
$325.05
|
| Rate for Payer: Quartz Beloit One Network |
$150.55
|
| Rate for Payer: Quartz Commercial |
$195.03
|
| Rate for Payer: Quartz Medicare Advantage |
$44.19
|
| Rate for Payer: The Alliance Commercial |
$187.81
|
| Rate for Payer: United Healthcare Medicaid |
$23.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.19
|
| Rate for Payer: WEA Trust Commercial |
$188.19
|
| Rate for Payer: WPS Commercial |
$198.85
|
|
|
Apply Forearm Splint, Static 29125
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 29125
|
| Hospital Charge Code |
3014294
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$213.41 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Aetna Managed Medicare |
$39.61
|
| Rate for Payer: Anthem Medicare Advantage |
$39.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.61
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$213.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.61
|
| Rate for Payer: Health EOS Commercial |
$204.42
|
| Rate for Payer: HFN Commercial |
$213.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.61
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: NAPHCARE Commercial |
$59.42
|
| Rate for Payer: Preferred Network Access Commercial |
$213.41
|
| Rate for Payer: Quartz Beloit One Network |
$98.84
|
| Rate for Payer: Quartz Commercial |
$128.04
|
| Rate for Payer: Quartz Medicare Advantage |
$39.61
|
| Rate for Payer: The Alliance Commercial |
$168.36
|
| Rate for Payer: United Healthcare Medicaid |
$28.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.61
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$178.26
|
|
|
APPLY HAND/WRIST CAST 29085
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 29085
|
| Hospital Charge Code |
3014291
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.52 |
| Max. Negotiated Rate |
$273.87 |
| Rate for Payer: Aetna Commercial |
$190.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$60.86
|
| Rate for Payer: Anthem Medicare Advantage |
$60.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.86
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$190.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.86
|
| Rate for Payer: Health EOS Commercial |
$182.66
|
| Rate for Payer: HFN Commercial |
$190.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$229.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$229.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.86
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$91.29
|
| Rate for Payer: Preferred Network Access Commercial |
$190.68
|
| Rate for Payer: Quartz Beloit One Network |
$88.32
|
| Rate for Payer: Quartz Commercial |
$114.41
|
| Rate for Payer: Quartz Medicare Advantage |
$60.86
|
| Rate for Payer: The Alliance Commercial |
$258.66
|
| Rate for Payer: United Healthcare Medicaid |
$50.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.86
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$273.87
|
|
|
APPLY LONG ARM SPLINT 29105
|
Professional
|
Both
|
$251.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3014293
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.90 |
| Max. Negotiated Rate |
$247.99 |
| Rate for Payer: Aetna Commercial |
$247.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Aetna Managed Medicare |
$34.90
|
| Rate for Payer: Anthem Medicare Advantage |
$34.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.90
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$247.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.90
|
| Rate for Payer: Health EOS Commercial |
$237.55
|
| Rate for Payer: HFN Commercial |
$247.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34.90
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: NAPHCARE Commercial |
$52.35
|
| Rate for Payer: Preferred Network Access Commercial |
$247.99
|
| Rate for Payer: Quartz Beloit One Network |
$114.86
|
| Rate for Payer: Quartz Commercial |
$148.79
|
| Rate for Payer: Quartz Medicare Advantage |
$34.90
|
| Rate for Payer: The Alliance Commercial |
$148.34
|
| Rate for Payer: United Healthcare Medicaid |
$46.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.90
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$157.06
|
|
|
Apply Short Leg Cast 29405PP
|
Professional
|
Both
|
$422.00
|
|
|
Service Code
|
CPT 29405
|
| Hospital Charge Code |
3925359
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.78 |
| Max. Negotiated Rate |
$416.94 |
| Rate for Payer: Aetna Commercial |
$416.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$377.44
|
| Rate for Payer: Aetna Managed Medicare |
$53.78
|
| Rate for Payer: Anthem Medicare Advantage |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.78
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$416.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.78
|
| Rate for Payer: Health EOS Commercial |
$399.38
|
| Rate for Payer: HFN Commercial |
$416.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.78
|
| Rate for Payer: Multiplan Commercial |
$351.10
|
| Rate for Payer: NAPHCARE Commercial |
$80.67
|
| Rate for Payer: Preferred Network Access Commercial |
$416.94
|
| Rate for Payer: Quartz Beloit One Network |
$193.11
|
| Rate for Payer: Quartz Commercial |
$250.16
|
| Rate for Payer: Quartz Medicare Advantage |
$53.78
|
| Rate for Payer: The Alliance Commercial |
$228.56
|
| Rate for Payer: United Healthcare Medicaid |
$75.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.78
|
| Rate for Payer: WEA Trust Commercial |
$241.38
|
| Rate for Payer: WPS Commercial |
$242.00
|
|
|
Apply Short Leg Cast 29425PP
|
Professional
|
Both
|
$476.00
|
|
|
Service Code
|
CPT 29425
|
| Hospital Charge Code |
3263486
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.02 |
| Max. Negotiated Rate |
$470.29 |
| Rate for Payer: Aetna Commercial |
$470.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.73
|
| Rate for Payer: Aetna Managed Medicare |
$50.02
|
| Rate for Payer: Anthem Medicare Advantage |
$50.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.02
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$470.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.02
|
| Rate for Payer: Health EOS Commercial |
$450.49
|
| Rate for Payer: HFN Commercial |
$470.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$189.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.02
|
| Rate for Payer: Multiplan Commercial |
$396.03
|
| Rate for Payer: NAPHCARE Commercial |
$75.04
|
| Rate for Payer: Preferred Network Access Commercial |
$470.29
|
| Rate for Payer: Quartz Beloit One Network |
$217.82
|
| Rate for Payer: Quartz Commercial |
$282.17
|
| Rate for Payer: Quartz Medicare Advantage |
$50.02
|
| Rate for Payer: The Alliance Commercial |
$212.60
|
| Rate for Payer: United Healthcare Medicaid |
$77.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.02
|
| Rate for Payer: WEA Trust Commercial |
$272.27
|
| Rate for Payer: WPS Commercial |
$225.11
|
|
|
APPLY SHORT LEG CAST 29435
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
CPT 29435
|
| Hospital Charge Code |
3014301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.13 |
| Max. Negotiated Rate |
$395.20 |
| Rate for Payer: Aetna Commercial |
$395.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Aetna Managed Medicare |
$77.13
|
| Rate for Payer: Anthem Medicare Advantage |
$77.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$77.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$77.13
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.13
|
| Rate for Payer: Health EOS Commercial |
$378.56
|
| Rate for Payer: HFN Commercial |
$395.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$77.13
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$115.69
|
| Rate for Payer: Preferred Network Access Commercial |
$395.20
|
| Rate for Payer: Quartz Beloit One Network |
$183.04
|
| Rate for Payer: Quartz Commercial |
$237.12
|
| Rate for Payer: Quartz Medicare Advantage |
$77.13
|
| Rate for Payer: The Alliance Commercial |
$327.79
|
| Rate for Payer: United Healthcare Medicaid |
$85.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$77.13
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$347.07
|
|
|
App of Low Cost Skin Substitute T/A/L each addtl 25 sq cm C5272
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS C5272
|
| Hospital Charge Code |
5506781
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.98 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.79
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
App of Low Cost Skin Substitute T/A/L First 25 sq cm C5271
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
5506780
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$169.31 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$365.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$365.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.88
|
| Rate for Payer: Health EOS Commercial |
$350.17
|
| Rate for Payer: HFN Commercial |
$365.56
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$365.56
|
| Rate for Payer: Quartz Beloit One Network |
$169.31
|
| Rate for Payer: Quartz Commercial |
$219.34
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
App of multi-layer venous wound compression system, below knee 29581PP
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 29581
|
| Hospital Charge Code |
4728606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.60 |
| Max. Negotiated Rate |
$206.49 |
| Rate for Payer: Aetna Commercial |
$206.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Aetna Managed Medicare |
$23.60
|
| Rate for Payer: Anthem Medicare Advantage |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.60
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$206.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.60
|
| Rate for Payer: Health EOS Commercial |
$197.80
|
| Rate for Payer: HFN Commercial |
$206.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.60
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$206.49
|
| Rate for Payer: Quartz Beloit One Network |
$95.64
|
| Rate for Payer: Quartz Commercial |
$123.90
|
| Rate for Payer: Quartz Medicare Advantage |
$23.60
|
| Rate for Payer: The Alliance Commercial |
$100.29
|
| Rate for Payer: United Healthcare Medicaid |
$74.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.60
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$106.19
|
|
|
App of skin graft to arms, legs, wound surface area >=100sq cm 15273
|
Professional
|
Both
|
$930.00
|
|
|
Service Code
|
CPT 15273
|
| Hospital Charge Code |
4596904
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$162.02 |
| Max. Negotiated Rate |
$918.84 |
| Rate for Payer: Aetna Commercial |
$918.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$831.79
|
| Rate for Payer: Aetna Managed Medicare |
$162.02
|
| Rate for Payer: Anthem Medicare Advantage |
$162.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$162.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$162.02
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$918.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$231.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.02
|
| Rate for Payer: Health EOS Commercial |
$880.15
|
| Rate for Payer: HFN Commercial |
$918.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$674.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$674.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$162.02
|
| Rate for Payer: Multiplan Commercial |
$773.76
|
| Rate for Payer: NAPHCARE Commercial |
$243.03
|
| Rate for Payer: Preferred Network Access Commercial |
$918.84
|
| Rate for Payer: Quartz Beloit One Network |
$425.57
|
| Rate for Payer: Quartz Commercial |
$551.30
|
| Rate for Payer: Quartz Medicare Advantage |
$162.02
|
| Rate for Payer: The Alliance Commercial |
$688.59
|
| Rate for Payer: United Healthcare Medicaid |
$231.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$162.02
|
| Rate for Payer: WEA Trust Commercial |
$531.96
|
| Rate for Payer: WPS Commercial |
$729.10
|
|
