|
PREMIUM WRIST SPLINT (LL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974389
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
Preop Ostomy Counseling
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Preop Ostomy Counseling
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Prep J& Antigen Allergen Immunotherapy 2 Insect 95146
|
Professional
|
Both
|
$188.00
|
|
|
Service Code
|
CPT 95146
|
| Hospital Charge Code |
5102641
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.80 |
| Max. Negotiated Rate |
$213.14 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.80
|
| Rate for Payer: Health EOS Commercial |
$171.08
|
| Rate for Payer: HFN Commercial |
$178.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.14
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.60
|
| Rate for Payer: Quartz Beloit One Network |
$82.72
|
| Rate for Payer: Quartz Commercial |
$107.16
|
| Rate for Payer: The Alliance Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicaid |
$36.80
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
IP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.02 |
| Max. Negotiated Rate |
$182.16 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$118.80
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
OP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.44 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Aetna Managed Medicare |
$55.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.80
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.50
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$128.70
|
| Rate for Payer: Quartz Medicare Advantage |
$118.80
|
| Rate for Payer: The Alliance Commercial |
$792.00
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
PRESSURE REGULATING BALLON 61-70CM H20 72400024
|
Facility
|
OP
|
$16,276.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,557.28 |
| Max. Negotiated Rate |
$65,104.00 |
| Rate for Payer: Aetna Commercial |
$14,648.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,997.36
|
| Rate for Payer: Aetna Managed Medicare |
$4,557.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,579.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,138.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,812.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,626.28
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$14,973.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,108.05
|
| Rate for Payer: Health EOS Commercial |
$14,485.64
|
| Rate for Payer: HFN Commercial |
$14,973.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,207.00
|
| Rate for Payer: Multiplan Commercial |
$13,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,973.92
|
| Rate for Payer: Quartz Beloit One Network |
$7,975.24
|
| Rate for Payer: Quartz Commercial |
$10,579.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,765.60
|
| Rate for Payer: The Alliance Commercial |
$65,104.00
|
| Rate for Payer: WEA Trust Commercial |
$8,951.80
|
| Rate for Payer: WPS Commercial |
$12,055.63
|
|
|
PRESSURE REGULATING BALLON 61-70CM H20 72400024
|
Facility
|
IP
|
$16,276.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,975.24 |
| Max. Negotiated Rate |
$14,973.92 |
| Rate for Payer: Aetna Commercial |
$14,648.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,997.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,626.28
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$14,973.92
|
| Rate for Payer: Health EOS Commercial |
$14,485.64
|
| Rate for Payer: HFN Commercial |
$14,973.92
|
| Rate for Payer: Multiplan Commercial |
$13,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,973.92
|
| Rate for Payer: Quartz Beloit One Network |
$7,975.24
|
| Rate for Payer: Quartz Commercial |
$9,765.60
|
| Rate for Payer: WEA Trust Commercial |
$8,951.80
|
| Rate for Payer: WPS Commercial |
$12,055.63
|
|
|
PRESSURE REGULATING BALLON 71-80CM H20 72400025
|
Facility
|
IP
|
$16,160.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,918.40 |
| Max. Negotiated Rate |
$14,867.20 |
| Rate for Payer: Aetna Commercial |
$14,544.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,897.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,564.80
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$14,867.20
|
| Rate for Payer: Health EOS Commercial |
$14,382.40
|
| Rate for Payer: HFN Commercial |
$14,867.20
|
| Rate for Payer: Multiplan Commercial |
$12,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,867.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,918.40
|
| Rate for Payer: Quartz Commercial |
$9,696.00
|
| Rate for Payer: WEA Trust Commercial |
$8,888.00
|
| Rate for Payer: WPS Commercial |
$11,969.71
|
|
|
PRESSURE REGULATING BALLON 71-80CM H20 72400025
|
Facility
|
OP
|
$16,160.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,524.80 |
| Max. Negotiated Rate |
$64,640.00 |
| Rate for Payer: Aetna Commercial |
$14,544.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,897.60
|
| Rate for Payer: Aetna Managed Medicare |
$4,524.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,504.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,756.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,564.80
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$14,867.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,043.14
|
| Rate for Payer: Health EOS Commercial |
$14,382.40
|
| Rate for Payer: HFN Commercial |
$14,867.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,120.00
|
| Rate for Payer: Multiplan Commercial |
$12,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,867.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,918.40
|
| Rate for Payer: Quartz Commercial |
$10,504.00
|
| Rate for Payer: Quartz Medicare Advantage |
$9,696.00
|
| Rate for Payer: The Alliance Commercial |
$64,640.00
|
| Rate for Payer: WEA Trust Commercial |
$8,888.00
|
| Rate for Payer: WPS Commercial |
$11,969.71
|
|
|
Pre-TR ABO/Rh
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$209.59
|
| Rate for Payer: Anthem Medicaid |
$3.09
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Dean Health Medicaid |
$3.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicaid |
$3.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.09
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicaid |
$3.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WMAP Medicaid |
$3.09
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Pre-TR ABO/Rh
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Pre-Transfusion Reaction ABSC
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$114.60
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Pre-Transfusion Reaction ABSC
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$214.24 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$53.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.91
|
| Rate for Payer: Anthem Medicaid |
$5.38
|
| Rate for Payer: Anthem Medicare Advantage |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.56
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Dean Health Medicaid |
$5.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.56
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$80.34
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.38
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$53.56
|
| Rate for Payer: The Alliance Commercial |
$214.24
|
| Rate for Payer: United Healthcare Medicaid |
$5.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.56
|
| Rate for Payer: United Healthcare PPO |
$143.25
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: Wellcare Medicare |
$53.56
|
| Rate for Payer: WMAP Medicaid |
$5.38
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Pre-Transfusion Reaction DAT
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973779
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$76.50
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
