|
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 (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 (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 (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 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
|
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
|
|
|
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 71-80CM H20 72400025
|
Facility
|
OP
|
$16,160.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,705.79 |
| Max. Negotiated Rate |
$15,461.89 |
| Rate for Payer: Aetna Commercial |
$15,125.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,453.50
|
| Rate for Payer: Aetna Managed Medicare |
$4,705.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,924.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,403.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,067.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,907.39
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$15,461.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,405.12
|
| Rate for Payer: Health EOS Commercial |
$14,957.70
|
| Rate for Payer: HFN Commercial |
$15,461.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,604.80
|
| Rate for Payer: Multiplan Commercial |
$13,445.12
|
| Rate for Payer: NAPHCARE Commercial |
$10,083.84
|
| Rate for Payer: Preferred Network Access Commercial |
$15,461.89
|
| Rate for Payer: Quartz Beloit One Network |
$8,235.14
|
| Rate for Payer: Quartz Commercial |
$10,924.16
|
| Rate for Payer: Quartz Medicare Advantage |
$10,083.84
|
| Rate for Payer: The Alliance Commercial |
$8,403.20
|
| Rate for Payer: WEA Trust Commercial |
$9,243.52
|
| Rate for Payer: WPS Commercial |
$12,448.05
|
|
|
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 |
$8,235.14 |
| Max. Negotiated Rate |
$15,461.89 |
| Rate for Payer: Aetna Commercial |
$15,125.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,453.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,907.39
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$15,461.89
|
| Rate for Payer: Health EOS Commercial |
$14,957.70
|
| Rate for Payer: HFN Commercial |
$15,461.89
|
| Rate for Payer: Multiplan Commercial |
$13,445.12
|
| Rate for Payer: Preferred Network Access Commercial |
$15,461.89
|
| Rate for Payer: Quartz Beloit One Network |
$8,235.14
|
| Rate for Payer: Quartz Commercial |
$10,083.84
|
| Rate for Payer: WEA Trust Commercial |
$9,243.52
|
| Rate for Payer: WPS Commercial |
$12,448.05
|
|
|
PRESSURE ULCERS
|
Facility
|
OP
|
$29.19
|
|
|
Service Code
|
EAPG 00676
|
| Min. Negotiated Rate |
$28.06 |
| Max. Negotiated Rate |
$29.19 |
| Rate for Payer: Anthem Medicaid |
$28.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.06
|
| Rate for Payer: Dean Health Medicaid |
$28.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$28.06
|
| Rate for Payer: Managed Health Services Medicaid |
$29.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28.06
|
| Rate for Payer: United Healthcare Medicaid |
$28.06
|
|
|
PRETERM LABOR DIAGNOSES
|
Facility
|
OP
|
$84.74
|
|
|
Service Code
|
EAPG 00762
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$84.74 |
| Rate for Payer: Anthem Medicaid |
$81.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$81.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.48
|
| Rate for Payer: Dean Health Medicaid |
$81.48
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$81.48
|
| Rate for Payer: Managed Health Services Medicaid |
$84.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$81.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$81.48
|
| Rate for Payer: United Healthcare Medicaid |
$81.48
|
|
|
Pre-TR ABO/Rh
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$53.66
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
Pre-TR ABO/Rh
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$492.41 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Aetna Managed Medicare |
$3.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$492.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$229.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$217.98
|
| Rate for Payer: Anthem Medicare Advantage |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.11
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.11
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: NAPHCARE Commercial |
$4.66
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$3.11
|
| Rate for Payer: The Alliance Commercial |
$12.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.11
|
| Rate for Payer: United Healthcare PPO |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: Wellcare Medicare |
$3.11
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
