|
Preg Serum
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Preg Serum
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Aetna Commercial |
$137.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$7.82
|
| Rate for Payer: Anthem Medicare Advantage |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.82
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$137.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.82
|
| Rate for Payer: Health EOS Commercial |
$131.55
|
| Rate for Payer: HFN Commercial |
$137.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$11.73
|
| Rate for Payer: Preferred Network Access Commercial |
$137.33
|
| Rate for Payer: Quartz Beloit One Network |
$63.61
|
| Rate for Payer: Quartz Commercial |
$82.40
|
| Rate for Payer: Quartz Medicare Advantage |
$7.82
|
| Rate for Payer: The Alliance Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.82
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$34.41
|
|
|
PREMATURITY WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$113,632.48
|
|
|
Service Code
|
MSDRG 791
|
| Min. Negotiated Rate |
$2,496.00 |
| Max. Negotiated Rate |
$113,632.48 |
| Rate for Payer: Aetna Managed Medicare |
$31,591.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,242.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,583.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,403.92
|
| Rate for Payer: Anthem Medicare Advantage |
$31,591.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31,591.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31,591.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$31,591.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71,594.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$31,591.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,108.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31,591.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31,591.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$31,591.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$31,591.41
|
| Rate for Payer: NAPHCARE Commercial |
$47,387.12
|
| Rate for Payer: Quartz Medicare Advantage |
$31,591.41
|
| Rate for Payer: The Alliance Commercial |
$113,632.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31,591.41
|
| Rate for Payer: United Healthcare PPO |
$2,496.00
|
| Rate for Payer: Wellcare Medicare |
$31,591.41
|
|
|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$68,696.16
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$1,664.00 |
| Max. Negotiated Rate |
$68,696.16 |
| Rate for Payer: Aetna Managed Medicare |
$19,263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,702.48
|
| Rate for Payer: Anthem Medicare Advantage |
$19,263.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,263.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,263.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,263.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43,199.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,263.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,016.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,263.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,263.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,263.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,263.24
|
| Rate for Payer: NAPHCARE Commercial |
$28,894.87
|
| Rate for Payer: Quartz Medicare Advantage |
$19,263.24
|
| Rate for Payer: The Alliance Commercial |
$68,696.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,263.24
|
| Rate for Payer: United Healthcare PPO |
$1,664.00
|
| Rate for Payer: Wellcare Medicare |
$19,263.24
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
OP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,421.64 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,421.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,300.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,538.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,437.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,841.32
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,807.96
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,046.37
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,300.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,046.37
|
| Rate for Payer: The Alliance Commercial |
$2,538.64
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
IP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,487.87 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,046.37
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
|
PREMIUM WRIST SPLINT (LL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974389
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (LL)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974389
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.26 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Aetna Managed Medicare |
$97.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.39
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.52
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: NAPHCARE Commercial |
$208.42
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$225.78
|
| Rate for Payer: Quartz Medicare Advantage |
$208.42
|
| Rate for Payer: The Alliance Commercial |
$173.68
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.21 |
| Max. Negotiated Rate |
$319.57 |
| Rate for Payer: Aetna Commercial |
$312.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.10
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$319.57
|
| Rate for Payer: Health EOS Commercial |
$309.15
|
| Rate for Payer: HFN Commercial |
$319.57
|
| Rate for Payer: Multiplan Commercial |
$277.89
|
| Rate for Payer: Preferred Network Access Commercial |
$319.57
|
| Rate for Payer: Quartz Beloit One Network |
$170.21
|
| Rate for Payer: Quartz Commercial |
$208.42
|
| Rate for Payer: WEA Trust Commercial |
$191.05
|
| Rate for Payer: WPS Commercial |
$257.28
|
|
|
Preop Ostomy Counseling
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$109.05 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$133.54
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
Preop Ostomy Counseling
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Aetna Managed Medicare |
$62.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.55
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.92
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: NAPHCARE Commercial |
$133.54
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$144.66
|
| Rate for Payer: Quartz Medicare Advantage |
$133.54
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
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 |
$2.53 |
| Max. Negotiated Rate |
$221.67 |
| Rate for Payer: Aetna Commercial |
$185.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.15
|
| Rate for Payer: Aetna Managed Medicare |
$2.53
|
| Rate for Payer: Anthem Medicare Advantage |
$2.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.53
|
| 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 |
$185.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.53
|
| Rate for Payer: Health EOS Commercial |
$177.92
|
| Rate for Payer: HFN Commercial |
$185.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$221.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$221.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.53
|
| Rate for Payer: Multiplan Commercial |
$156.42
|
| Rate for Payer: NAPHCARE Commercial |
$3.79
|
| Rate for Payer: Preferred Network Access Commercial |
$185.74
|
| Rate for Payer: Quartz Beloit One Network |
$86.03
|
| Rate for Payer: Quartz Commercial |
$111.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2.53
|
| Rate for Payer: The Alliance Commercial |
$6.32
|
| Rate for Payer: United Healthcare Medicaid |
$38.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.53
|
| Rate for Payer: WEA Trust Commercial |
$107.54
|
| Rate for Payer: WPS Commercial |
$10.11
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
OP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.66 |
| Max. Negotiated Rate |
$189.45 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Aetna Managed Medicare |
$57.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.24
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.44
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: NAPHCARE Commercial |
$123.55
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$133.85
|
| Rate for Payer: Quartz Medicare Advantage |
$123.55
|
| Rate for Payer: The Alliance Commercial |
$102.96
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
IP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.90 |
| Max. Negotiated Rate |
$189.45 |
| Rate for Payer: Aetna Commercial |
$185.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.14
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$189.45
|
| Rate for Payer: Health EOS Commercial |
$183.27
|
| Rate for Payer: HFN Commercial |
$189.45
|
| Rate for Payer: Multiplan Commercial |
$164.74
|
| Rate for Payer: Preferred Network Access Commercial |
$189.45
|
| Rate for Payer: Quartz Beloit One Network |
$100.90
|
| Rate for Payer: Quartz Commercial |
$123.55
|
| Rate for Payer: WEA Trust Commercial |
$113.26
|
| Rate for Payer: WPS Commercial |
$152.52
|
|
|
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 |
$8,294.25 |
| Max. Negotiated Rate |
$15,572.88 |
| Rate for Payer: Aetna Commercial |
$15,234.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,557.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,971.33
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$15,572.88
|
| Rate for Payer: Health EOS Commercial |
$15,065.07
|
| Rate for Payer: HFN Commercial |
$15,572.88
|
| Rate for Payer: Multiplan Commercial |
$13,541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$15,572.88
|
| Rate for Payer: Quartz Beloit One Network |
$8,294.25
|
| Rate for Payer: Quartz Commercial |
$10,156.22
|
| Rate for Payer: WEA Trust Commercial |
$9,309.87
|
| Rate for Payer: WPS Commercial |
$12,537.40
|
|
|
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 |
$4,739.57 |
| Max. Negotiated Rate |
$15,572.88 |
| Rate for Payer: Aetna Commercial |
$15,234.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,557.25
|
| Rate for Payer: Aetna Managed Medicare |
$4,739.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,002.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,463.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,124.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,971.33
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$15,572.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,472.63
|
| Rate for Payer: Health EOS Commercial |
$15,065.07
|
| Rate for Payer: HFN Commercial |
$15,572.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,695.28
|
| Rate for Payer: Multiplan Commercial |
$13,541.63
|
| Rate for Payer: NAPHCARE Commercial |
$10,156.22
|
| Rate for Payer: Preferred Network Access Commercial |
$15,572.88
|
| Rate for Payer: Quartz Beloit One Network |
$8,294.25
|
| Rate for Payer: Quartz Commercial |
$11,002.58
|
| Rate for Payer: Quartz Medicare Advantage |
$10,156.22
|
| Rate for Payer: The Alliance Commercial |
$8,463.52
|
| Rate for Payer: WEA Trust Commercial |
$9,309.87
|
| Rate for Payer: WPS Commercial |
$12,537.40
|
|
