|
Preg Serum
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$7.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Anthem Medicaid |
$7.77
|
| Rate for Payer: Anthem Medicare Advantage |
$7.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.52
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Dean Health Medicaid |
$7.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.52
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.52
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.52
|
| Rate for Payer: Managed Health Services Medicaid |
$8.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.52
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.28
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.77
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$7.52
|
| Rate for Payer: The Alliance Commercial |
$30.08
|
| Rate for Payer: United Healthcare Medicaid |
$7.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.52
|
| Rate for Payer: United Healthcare PPO |
$104.25
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: Wellcare Medicare |
$7.52
|
| Rate for Payer: WMAP Medicaid |
$7.77
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Preg Serum
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
PREMATURITY WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$109,262.00
|
|
|
Service Code
|
MSDRG 791
|
| Min. Negotiated Rate |
$2,400.00 |
| Max. Negotiated Rate |
$109,262.00 |
| Rate for Payer: Aetna Managed Medicare |
$39,302.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$39,302.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39,302.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39,302.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39,302.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69,535.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39,302.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79,905.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39,302.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39,302.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39,302.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39,302.78
|
| Rate for Payer: NAPHCARE Commercial |
$58,954.17
|
| Rate for Payer: Quartz Medicare Advantage |
$39,302.78
|
| Rate for Payer: The Alliance Commercial |
$109,262.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39,302.78
|
| Rate for Payer: United Healthcare PPO |
$2,400.00
|
| Rate for Payer: Wellcare Medicare |
$39,302.78
|
|
|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$66,054.00
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$1,600.00 |
| Max. Negotiated Rate |
$66,054.00 |
| Rate for Payer: Aetna Managed Medicare |
$23,760.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,637.00
|
| Rate for Payer: Anthem Medicare Advantage |
$23,760.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23,760.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23,760.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23,760.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41,891.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23,760.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48,213.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23,760.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23,760.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23,760.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23,760.51
|
| Rate for Payer: NAPHCARE Commercial |
$35,640.76
|
| Rate for Payer: Quartz Medicare Advantage |
$23,760.51
|
| Rate for Payer: The Alliance Commercial |
$66,054.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,760.51
|
| Rate for Payer: United Healthcare PPO |
$1,600.00
|
| Rate for Payer: Wellcare Medicare |
$23,760.51
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
OP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,366.96 |
| Max. Negotiated Rate |
$19,528.00 |
| Rate for Payer: Aetna Commercial |
$4,393.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,198.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,366.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,173.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,441.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,343.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,587.46
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,491.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,731.97
|
| Rate for Payer: Health EOS Commercial |
$4,344.98
|
| Rate for Payer: HFN Commercial |
$4,491.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,661.50
|
| Rate for Payer: Multiplan Commercial |
$3,905.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,929.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,491.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,392.18
|
| Rate for Payer: Quartz Commercial |
$3,173.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,929.20
|
| Rate for Payer: The Alliance Commercial |
$19,528.00
|
| Rate for Payer: WEA Trust Commercial |
$2,685.10
|
| Rate for Payer: WPS Commercial |
$3,616.10
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
IP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,392.18 |
| Max. Negotiated Rate |
$4,491.44 |
| Rate for Payer: Aetna Commercial |
$4,393.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,198.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,587.46
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,491.44
|
| Rate for Payer: Health EOS Commercial |
$4,344.98
|
| Rate for Payer: HFN Commercial |
$4,491.44
|
| Rate for Payer: Multiplan Commercial |
$3,905.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,929.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,491.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,392.18
|
| Rate for Payer: Quartz Commercial |
$2,929.20
|
| Rate for Payer: WEA Trust Commercial |
$2,685.10
|
| Rate for Payer: WPS Commercial |
$3,616.10
|
|
|
PREMIUM WRIST SPLINT (LL)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974389
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (LL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974389
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (LR)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974388
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT MED RT 351MR
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974391
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (ML)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974390
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (RS)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974393
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PREMIUM WRIST SPLINT (SL)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974392
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
Preop Ostomy Counseling
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Preop Ostomy Counseling
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005547
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Prep J& Antigen Allergen Immunotherapy 2 Insect 95146
|
Professional
|
Both
|
$188.00
|
|
|
Service Code
|
CPT 95146
|
| Hospital Charge Code |
5102641
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.80 |
| Max. Negotiated Rate |
$213.14 |
| Rate for Payer: Aetna Commercial |
$178.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$178.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.80
|
| Rate for Payer: Health EOS Commercial |
$171.08
|
| Rate for Payer: HFN Commercial |
$178.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.14
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.60
|
| Rate for Payer: Quartz Beloit One Network |
$82.72
|
| Rate for Payer: Quartz Commercial |
$107.16
|
| Rate for Payer: The Alliance Commercial |
$94.00
|
| Rate for Payer: United Healthcare Medicaid |
$36.80
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
OP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.44 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Aetna Managed Medicare |
$55.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.80
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.50
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$128.70
|
| Rate for Payer: Quartz Medicare Advantage |
$118.80
|
| Rate for Payer: The Alliance Commercial |
$792.00
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
PREP SOLUTION BETADINE 5% 30ML 0065-0411-30
|
Facility
|
IP
|
$198.00
|
|
| Hospital Charge Code |
4509072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.02 |
| Max. Negotiated Rate |
$182.16 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$118.80
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
PRESSURE REGULATING BALLON 61-70CM H20 72400024
|
Facility
|
OP
|
$16,276.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,557.28 |
| Max. Negotiated Rate |
$65,104.00 |
| Rate for Payer: Aetna Commercial |
$14,648.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,997.36
|
| Rate for Payer: Aetna Managed Medicare |
$4,557.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,579.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,138.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,812.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,626.28
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$14,973.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,108.05
|
| Rate for Payer: Health EOS Commercial |
$14,485.64
|
| Rate for Payer: HFN Commercial |
$14,973.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,207.00
|
| Rate for Payer: Multiplan Commercial |
$13,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,973.92
|
| Rate for Payer: Quartz Beloit One Network |
$7,975.24
|
| Rate for Payer: Quartz Commercial |
$10,579.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,765.60
|
| Rate for Payer: The Alliance Commercial |
$65,104.00
|
| Rate for Payer: WEA Trust Commercial |
$8,951.80
|
| Rate for Payer: WPS Commercial |
$12,055.63
|
|
|
PRESSURE REGULATING BALLON 61-70CM H20 72400024
|
Facility
|
IP
|
$16,276.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,975.24 |
| Max. Negotiated Rate |
$14,973.92 |
| Rate for Payer: Aetna Commercial |
$14,648.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,997.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,626.28
|
| Rate for Payer: Cash Price |
$4,882.80
|
| Rate for Payer: Cigna Commercial |
$14,973.92
|
| Rate for Payer: Health EOS Commercial |
$14,485.64
|
| Rate for Payer: HFN Commercial |
$14,973.92
|
| Rate for Payer: Multiplan Commercial |
$13,020.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,765.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,973.92
|
| Rate for Payer: Quartz Beloit One Network |
$7,975.24
|
| Rate for Payer: Quartz Commercial |
$9,765.60
|
| Rate for Payer: WEA Trust Commercial |
$8,951.80
|
| Rate for Payer: WPS Commercial |
$12,055.63
|
|
