|
POSITIONING PIN 5.0MM 02.231.022S
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
6178022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.50 |
| Max. Negotiated Rate |
$966.00 |
| Rate for Payer: Aetna Commercial |
$945.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$903.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$556.50
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$966.00
|
| Rate for Payer: Health EOS Commercial |
$934.50
|
| Rate for Payer: HFN Commercial |
$966.00
|
| Rate for Payer: Multiplan Commercial |
$840.00
|
| Rate for Payer: NAPHCARE Commercial |
$630.00
|
| Rate for Payer: Preferred Network Access Commercial |
$966.00
|
| Rate for Payer: Quartz Beloit One Network |
$514.50
|
| Rate for Payer: Quartz Commercial |
$630.00
|
| Rate for Payer: WEA Trust Commercial |
$577.50
|
| Rate for Payer: WPS Commercial |
$777.74
|
|
|
Positive - Rapid Strep Test
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
3052340
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.51 |
| Max. Negotiated Rate |
$183.08 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$119.40
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Positive - Rapid Strep Test
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
3052340
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$183.08 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Aetna Managed Medicare |
$16.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.44
|
| Rate for Payer: Anthem Medicaid |
$16.86
|
| Rate for Payer: Anthem Medicare Advantage |
$16.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.53
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.36
|
| Rate for Payer: Dean Health Medicaid |
$16.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.53
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.53
|
| Rate for Payer: Managed Health Services Medicaid |
$17.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.53
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$24.80
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.86
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$129.35
|
| Rate for Payer: Quartz Medicare Advantage |
$16.53
|
| Rate for Payer: The Alliance Commercial |
$66.12
|
| Rate for Payer: United Healthcare Medicaid |
$16.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.53
|
| Rate for Payer: United Healthcare PPO |
$149.25
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: Wellcare Medicare |
$16.53
|
| Rate for Payer: WMAP Medicaid |
$16.86
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Positive - Urine Pregnancy POC
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120176
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.32 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$100.80
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$100.80
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
Positive - Urine Pregnancy POC
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120176
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Aetna Managed Medicare |
$8.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.07
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.29
|
| Rate for Payer: Anthem Medicaid |
$8.90
|
| Rate for Payer: Anthem Medicare Advantage |
$8.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.61
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.01
|
| Rate for Payer: Dean Health Medicaid |
$8.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.61
|
| Rate for Payer: Managed Health Services Medicaid |
$9.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$12.92
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.90
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: Quartz Medicare Advantage |
$8.61
|
| Rate for Payer: The Alliance Commercial |
$34.44
|
| Rate for Payer: United Healthcare Medicaid |
$8.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.61
|
| Rate for Payer: United Healthcare PPO |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: Wellcare Medicare |
$8.61
|
| Rate for Payer: WMAP Medicaid |
$8.90
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 20MM AR-9561-20P
|
Facility
|
OP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,962.24 |
| Max. Negotiated Rate |
$28,032.00 |
| Rate for Payer: Aetna Commercial |
$6,307.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,026.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,962.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,555.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,504.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,363.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,714.24
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,447.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,921.68
|
| Rate for Payer: Health EOS Commercial |
$6,237.12
|
| Rate for Payer: HFN Commercial |
$6,447.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,256.00
|
| Rate for Payer: Multiplan Commercial |
$5,606.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,204.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,447.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,433.92
|
| Rate for Payer: Quartz Commercial |
$4,555.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,204.80
|
| Rate for Payer: The Alliance Commercial |
$28,032.00
|
| Rate for Payer: WEA Trust Commercial |
$3,854.40
|
| Rate for Payer: WPS Commercial |
$5,190.83
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 20MM AR-9561-20P
|
Facility
|
IP
|
$7,008.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6065665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,433.92 |
| Max. Negotiated Rate |
$6,447.36 |
| Rate for Payer: Aetna Commercial |
$6,307.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,026.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,714.24
|
| Rate for Payer: Cash Price |
$2,102.40
|
| Rate for Payer: Cigna Commercial |
$6,447.36
|
| Rate for Payer: Health EOS Commercial |
$6,237.12
|
| Rate for Payer: HFN Commercial |
$6,447.36
|
| Rate for Payer: Multiplan Commercial |
$5,606.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,204.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,447.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,433.92
|
| Rate for Payer: Quartz Commercial |
$4,204.80
|
| Rate for Payer: WEA Trust Commercial |
$3,854.40
|
| Rate for Payer: WPS Commercial |
$5,190.83
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 25MM AR-9561-25P
|
Facility
|
OP
|
$7,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,122.40 |
| Max. Negotiated Rate |
$30,320.00 |
| Rate for Payer: Aetna Commercial |
$6,822.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,518.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,122.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,927.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,790.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,638.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,017.40
|
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Cigna Commercial |
$6,973.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,241.77
|
| Rate for Payer: Health EOS Commercial |
$6,746.20
|
| Rate for Payer: HFN Commercial |
$6,973.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,685.00
|
| Rate for Payer: Multiplan Commercial |
$6,064.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,548.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,973.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,714.20
|
| Rate for Payer: Quartz Commercial |
$4,927.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,548.00
|
| Rate for Payer: The Alliance Commercial |
$30,320.00
|
| Rate for Payer: WEA Trust Commercial |
$4,169.00
|
| Rate for Payer: WPS Commercial |
$5,614.51
|
|
|
POST CENTRAL MODULAR UNIVERS REVERS MODULAR GLENOID 25MM AR-9561-25P
|
Facility
|
IP
|
$7,580.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563387
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,714.20 |
| Max. Negotiated Rate |
$6,973.60 |
| Rate for Payer: Aetna Commercial |
$6,822.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,518.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,017.40
|
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Cigna Commercial |
$6,973.60
|
| Rate for Payer: Health EOS Commercial |
$6,746.20
|
| Rate for Payer: HFN Commercial |
$6,973.60
|
| Rate for Payer: Multiplan Commercial |
$6,064.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,548.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,973.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,714.20
|
| Rate for Payer: Quartz Commercial |
$4,548.00
|
| Rate for Payer: WEA Trust Commercial |
$4,169.00
|
| Rate for Payer: WPS Commercial |
$5,614.51
|
|
|
Post ED Visit/ Called Back - ED Other Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
3228171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Post ED Visit/ Called Back - ED Other Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
3228171
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$87.75 |
| Max. Negotiated Rate |
$641.00 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Aetna Managed Medicare |
$87.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$641.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$436.00
|
| Rate for Payer: Anthem Medicare Advantage |
$87.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$87.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$87.75
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$87.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$87.75
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$326.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$87.75
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$87.75
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$87.75
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$131.62
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$148.20
|
| Rate for Payer: Quartz Medicare Advantage |
$87.75
|
| Rate for Payer: The Alliance Commercial |
$351.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.75
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: Wellcare Medicare |
$87.75
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Post ED Vist/Called Back - FCT03
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT FCT03
|
| Hospital Charge Code |
5516690
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.12 |
| Max. Negotiated Rate |
$1,216.00 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.44
|
| Rate for Payer: Aetna Managed Medicare |
$85.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$197.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$152.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.12
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$279.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.12
|
| Rate for Payer: Health EOS Commercial |
$270.56
|
| Rate for Payer: HFN Commercial |
$279.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.00
|
| Rate for Payer: Multiplan Commercial |
$243.20
|
| Rate for Payer: NAPHCARE Commercial |
$182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$279.68
|
| Rate for Payer: Quartz Beloit One Network |
$148.96
|
| Rate for Payer: Quartz Commercial |
$197.60
|
| Rate for Payer: Quartz Medicare Advantage |
$182.40
|
| Rate for Payer: The Alliance Commercial |
$1,216.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$167.20
|
| Rate for Payer: WPS Commercial |
$225.17
|
|
|
Post ED Vist/Called Back - FCT03
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT FCT03
|
| Hospital Charge Code |
5516690
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$148.96 |
| Max. Negotiated Rate |
$279.68 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$161.12
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$279.68
|
| Rate for Payer: Health EOS Commercial |
$270.56
|
| Rate for Payer: HFN Commercial |
$279.68
|
| Rate for Payer: Multiplan Commercial |
$243.20
|
| Rate for Payer: NAPHCARE Commercial |
$182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$279.68
|
| Rate for Payer: Quartz Beloit One Network |
$148.96
|
| Rate for Payer: Quartz Commercial |
$182.40
|
| Rate for Payer: WEA Trust Commercial |
$167.20
|
| Rate for Payer: WPS Commercial |
$225.17
|
|
|
Post-Emergency Delivery Care - Individual Charges
|
Facility
|
OP
|
$3,189.00
|
|
| Hospital Charge Code |
3003927
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$892.92 |
| Max. Negotiated Rate |
$12,756.00 |
| Rate for Payer: Aetna Commercial |
$2,870.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,742.54
|
| Rate for Payer: Aetna Managed Medicare |
$892.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,072.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,594.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,530.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,690.17
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$2,933.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,784.56
|
| Rate for Payer: Health EOS Commercial |
$2,838.21
|
| Rate for Payer: HFN Commercial |
$2,933.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,391.75
|
| Rate for Payer: Multiplan Commercial |
$2,551.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,913.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,933.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,562.61
|
| Rate for Payer: Quartz Commercial |
$2,072.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,913.40
|
| Rate for Payer: The Alliance Commercial |
$12,756.00
|
| Rate for Payer: United Healthcare PPO |
$2,391.75
|
| Rate for Payer: WEA Trust Commercial |
$1,753.95
|
| Rate for Payer: WPS Commercial |
$2,362.09
|
|
|
Post-Emergency Delivery Care - Individual Charges
|
Facility
|
IP
|
$3,189.00
|
|
| Hospital Charge Code |
3003927
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,562.61 |
| Max. Negotiated Rate |
$2,933.88 |
| Rate for Payer: Aetna Commercial |
$2,870.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,742.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,690.17
|
| Rate for Payer: Cash Price |
$956.70
|
| Rate for Payer: Cigna Commercial |
$2,933.88
|
| Rate for Payer: Health EOS Commercial |
$2,838.21
|
| Rate for Payer: HFN Commercial |
$2,933.88
|
| Rate for Payer: Multiplan Commercial |
$2,551.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,913.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,933.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,562.61
|
| Rate for Payer: Quartz Commercial |
$1,913.40
|
| Rate for Payer: WEA Trust Commercial |
$1,753.95
|
| Rate for Payer: WPS Commercial |
$2,362.09
|
|
|
POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY
|
Facility
|
OP
|
$19,665.00
|
|
|
Service Code
|
CPT 57250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,240.00 |
| Max. Negotiated Rate |
$19,665.00 |
| Rate for Payer: Aetna Managed Medicare |
$4,916.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,238.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,914.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,367.00
|
| Rate for Payer: Anthem Medicare Advantage |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,916.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,916.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,916.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,339.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,916.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,288.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,916.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,916.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,916.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,916.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,374.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4,916.25
|
| Rate for Payer: The Alliance Commercial |
$19,665.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,916.25
|
| Rate for Payer: United Healthcare PPO |
$4,240.00
|
| Rate for Payer: Wellcare Medicare |
$4,916.25
|
|
|
POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
|
Facility
|
IP
|
$8,339.00
|
|
| Hospital Charge Code |
2960309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,086.11 |
| Max. Negotiated Rate |
$7,671.88 |
| Rate for Payer: Aetna Commercial |
$7,505.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,171.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,419.67
|
| Rate for Payer: Cash Price |
$2,501.70
|
| Rate for Payer: Cigna Commercial |
$7,671.88
|
| Rate for Payer: Health EOS Commercial |
$7,421.71
|
| Rate for Payer: HFN Commercial |
$7,671.88
|
| Rate for Payer: Multiplan Commercial |
$6,671.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,003.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,671.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,086.11
|
| Rate for Payer: Quartz Commercial |
$5,003.40
|
| Rate for Payer: WEA Trust Commercial |
$4,586.45
|
| Rate for Payer: WPS Commercial |
$6,176.70
|
|
|
POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
|
Facility
|
OP
|
$8,339.00
|
|
| Hospital Charge Code |
2960309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,334.92 |
| Max. Negotiated Rate |
$33,356.00 |
| Rate for Payer: Aetna Commercial |
$7,505.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,171.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,334.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,420.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,169.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,002.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,419.67
|
| Rate for Payer: Cash Price |
$2,501.70
|
| Rate for Payer: Cigna Commercial |
$7,671.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,666.50
|
| Rate for Payer: Health EOS Commercial |
$7,421.71
|
| Rate for Payer: HFN Commercial |
$7,671.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,254.25
|
| Rate for Payer: Multiplan Commercial |
$6,671.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,003.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,671.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,086.11
|
| Rate for Payer: Quartz Commercial |
$5,420.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,003.40
|
| Rate for Payer: The Alliance Commercial |
$33,356.00
|
| Rate for Payer: WEA Trust Commercial |
$4,586.45
|
| Rate for Payer: WPS Commercial |
$6,176.70
|
|
|
POST.FEM.PRESSURIZER 65 DEG 0606-514-000
|
Facility
|
OP
|
$314.00
|
|
| Hospital Charge Code |
2963241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.92 |
| Max. Negotiated Rate |
$1,256.00 |
| Rate for Payer: Aetna Commercial |
$282.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.04
|
| Rate for Payer: Aetna Managed Medicare |
$87.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$204.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$157.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$150.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$166.42
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$288.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.71
|
| Rate for Payer: Health EOS Commercial |
$279.46
|
| Rate for Payer: HFN Commercial |
$288.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$235.50
|
| Rate for Payer: Multiplan Commercial |
$251.20
|
| Rate for Payer: NAPHCARE Commercial |
$188.40
|
| Rate for Payer: Preferred Network Access Commercial |
$288.88
|
| Rate for Payer: Quartz Beloit One Network |
$153.86
|
| Rate for Payer: Quartz Commercial |
$204.10
|
| Rate for Payer: Quartz Medicare Advantage |
$188.40
|
| Rate for Payer: The Alliance Commercial |
$1,256.00
|
| Rate for Payer: WEA Trust Commercial |
$172.70
|
| Rate for Payer: WPS Commercial |
$232.58
|
|
|
POST.FEM.PRESSURIZER 65 DEG 0606-514-000
|
Facility
|
IP
|
$314.00
|
|
| Hospital Charge Code |
2963241
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.86 |
| Max. Negotiated Rate |
$288.88 |
| Rate for Payer: Aetna Commercial |
$282.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$166.42
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cigna Commercial |
$288.88
|
| Rate for Payer: Health EOS Commercial |
$279.46
|
| Rate for Payer: HFN Commercial |
$288.88
|
| Rate for Payer: Multiplan Commercial |
$251.20
|
| Rate for Payer: NAPHCARE Commercial |
$188.40
|
| Rate for Payer: Preferred Network Access Commercial |
$288.88
|
| Rate for Payer: Quartz Beloit One Network |
$153.86
|
| Rate for Payer: Quartz Commercial |
$188.40
|
| Rate for Payer: WEA Trust Commercial |
$172.70
|
| Rate for Payer: WPS Commercial |
$232.58
|
|
|
POST HOFFMANN 3 LARGE 30 DEG 4922-2-140
|
Facility
|
IP
|
$1,479.00
|
|
| Hospital Charge Code |
5685710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$724.71 |
| Max. Negotiated Rate |
$1,360.68 |
| Rate for Payer: Aetna Commercial |
$1,331.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,271.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$783.87
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$1,360.68
|
| Rate for Payer: Health EOS Commercial |
$1,316.31
|
| Rate for Payer: HFN Commercial |
$1,360.68
|
| Rate for Payer: Multiplan Commercial |
$1,183.20
|
| Rate for Payer: NAPHCARE Commercial |
$887.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,360.68
|
| Rate for Payer: Quartz Beloit One Network |
$724.71
|
| Rate for Payer: Quartz Commercial |
$887.40
|
| Rate for Payer: WEA Trust Commercial |
$813.45
|
| Rate for Payer: WPS Commercial |
$1,095.50
|
|
|
POST HOFFMANN 3 LARGE 30 DEG 4922-2-140
|
Facility
|
OP
|
$1,479.00
|
|
| Hospital Charge Code |
5685710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.12 |
| Max. Negotiated Rate |
$5,916.00 |
| Rate for Payer: Aetna Commercial |
$1,331.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,271.94
|
| Rate for Payer: Aetna Managed Medicare |
$414.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$961.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$739.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$709.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$783.87
|
| Rate for Payer: Cash Price |
$443.70
|
| Rate for Payer: Cigna Commercial |
$1,360.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$827.65
|
| Rate for Payer: Health EOS Commercial |
$1,316.31
|
| Rate for Payer: HFN Commercial |
$1,360.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,109.25
|
| Rate for Payer: Multiplan Commercial |
$1,183.20
|
| Rate for Payer: NAPHCARE Commercial |
$887.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,360.68
|
| Rate for Payer: Quartz Beloit One Network |
$724.71
|
| Rate for Payer: Quartz Commercial |
$961.35
|
| Rate for Payer: Quartz Medicare Advantage |
$887.40
|
| Rate for Payer: The Alliance Commercial |
$5,916.00
|
| Rate for Payer: WEA Trust Commercial |
$813.45
|
| Rate for Payer: WPS Commercial |
$1,095.50
|
|
|
POST MODULAR 20MM AR-9582-20
|
Facility
|
IP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,633.35 |
| Max. Negotiated Rate |
$6,821.80 |
| Rate for Payer: Aetna Commercial |
$6,673.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,376.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,929.95
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$6,821.80
|
| Rate for Payer: Health EOS Commercial |
$6,599.35
|
| Rate for Payer: HFN Commercial |
$6,821.80
|
| Rate for Payer: Multiplan Commercial |
$5,932.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,449.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,821.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,633.35
|
| Rate for Payer: Quartz Commercial |
$4,449.00
|
| Rate for Payer: WEA Trust Commercial |
$4,078.25
|
| Rate for Payer: WPS Commercial |
$5,492.29
|
|
|
POST MODULAR 20MM AR-9582-20
|
Facility
|
OP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,076.20 |
| Max. Negotiated Rate |
$29,660.00 |
| Rate for Payer: Aetna Commercial |
$6,673.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,376.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,076.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,819.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,707.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,559.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,929.95
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$6,821.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,149.43
|
| Rate for Payer: Health EOS Commercial |
$6,599.35
|
| Rate for Payer: HFN Commercial |
$6,821.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,561.25
|
| Rate for Payer: Multiplan Commercial |
$5,932.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,449.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,821.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,633.35
|
| Rate for Payer: Quartz Commercial |
$4,819.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,449.00
|
| Rate for Payer: The Alliance Commercial |
$29,660.00
|
| Rate for Payer: WEA Trust Commercial |
$4,078.25
|
| Rate for Payer: WPS Commercial |
$5,492.29
|
|
|
POST MODULAR 25MM AR-9582-25
|
Facility
|
OP
|
$7,415.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,076.20 |
| Max. Negotiated Rate |
$29,660.00 |
| Rate for Payer: Aetna Commercial |
$6,673.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,376.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,076.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,819.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,707.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,559.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,929.95
|
| Rate for Payer: Cash Price |
$2,224.50
|
| Rate for Payer: Cigna Commercial |
$6,821.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,149.43
|
| Rate for Payer: Health EOS Commercial |
$6,599.35
|
| Rate for Payer: HFN Commercial |
$6,821.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,561.25
|
| Rate for Payer: Multiplan Commercial |
$5,932.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,449.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,821.80
|
| Rate for Payer: Quartz Beloit One Network |
$3,633.35
|
| Rate for Payer: Quartz Commercial |
$4,819.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,449.00
|
| Rate for Payer: The Alliance Commercial |
$29,660.00
|
| Rate for Payer: WEA Trust Commercial |
$4,078.25
|
| Rate for Payer: WPS Commercial |
$5,492.29
|
|
