|
Pre-Transfusion Reaction ABSC
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$208.88 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Aetna Managed Medicare |
$10.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.47
|
| Rate for Payer: Anthem Medicare Advantage |
$10.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.16
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.16
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.16
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: NAPHCARE Commercial |
$15.24
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$129.12
|
| Rate for Payer: Quartz Medicare Advantage |
$10.16
|
| Rate for Payer: The Alliance Commercial |
$40.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.16
|
| Rate for Payer: United Healthcare PPO |
$148.98
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: Wellcare Medicare |
$10.16
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
Pre-Transfusion Reaction ABSC
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.33 |
| Max. Negotiated Rate |
$182.75 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$119.18
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
Pre-Transfusion Reaction DAT
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973779
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
Pre-Transfusion Reaction DAT
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973779
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$235.79 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$5.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.61
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.61
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$8.41
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$68.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5.61
|
| Rate for Payer: The Alliance Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.61
|
| Rate for Payer: United Healthcare PPO |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: Wellcare Medicare |
$5.61
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
Pre-Transfusion Reaction XM
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
973780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
Pre-Transfusion Reaction XM
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
973780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$127.76
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$147.42
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
PREVENTIVE DENTAL PROCEDURES
|
Facility
|
OP
|
$29.31
|
|
|
Service Code
|
EAPG 00377
|
| Min. Negotiated Rate |
$28.18 |
| Max. Negotiated Rate |
$29.31 |
| Rate for Payer: Anthem Medicaid |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.18
|
| Rate for Payer: Dean Health Medicaid |
$28.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$28.18
|
| Rate for Payer: Managed Health Services Medicaid |
$29.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28.18
|
| Rate for Payer: United Healthcare Medicaid |
$28.18
|
|
|
Preventive Medicine, Individual Counseling; 15 Minutes
|
Professional
|
Both
|
$131.00
|
|
|
Service Code
|
CPT 99401
|
| Hospital Charge Code |
1122875
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$129.43 |
| Rate for Payer: Aetna Commercial |
$129.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$129.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.74
|
| Rate for Payer: Health EOS Commercial |
$123.98
|
| Rate for Payer: HFN Commercial |
$129.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.95
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: Preferred Network Access Commercial |
$129.43
|
| Rate for Payer: Quartz Beloit One Network |
$59.95
|
| Rate for Payer: Quartz Commercial |
$77.66
|
| Rate for Payer: The Alliance Commercial |
$68.12
|
| Rate for Payer: United Healthcare Medicaid |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
PREVENTIVE OR SCREENING ENCOUNTER
|
Facility
|
OP
|
$31.83
|
|
|
Service Code
|
EAPG 00879
|
| Min. Negotiated Rate |
$30.61 |
| Max. Negotiated Rate |
$31.83 |
| Rate for Payer: Anthem Medicaid |
$30.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$30.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.61
|
| Rate for Payer: Dean Health Medicaid |
$30.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.61
|
| Rate for Payer: Managed Health Services Medicaid |
$31.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.61
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.61
|
| Rate for Payer: United Healthcare Medicaid |
$30.61
|
|
|
PRGRMG DEV EVAL SCRMS PHYS/QHP REMOTE 0650T
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
CPT 0650T
|
| Hospital Charge Code |
5901633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
PRIAPISM, CORRECTION OF/CORPORAL IRRIGATION/PENILE CORPUS CAVERNOSUM REPAIR
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
PRIAPISM, CORRECTION OF/CORPORAL IRRIGATION/PENILE CORPUS CAVERNOSUM REPAIR
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
Primatrix per sq cm Q4110
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.97 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$229.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$176.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.73
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$229.84
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Primatrix per sq cm Q4110
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.26 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Primatrix per sq cm Q4110
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.79 |
| Max. Negotiated Rate |
$348.66 |
| Rate for Payer: Aetna Commercial |
$335.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$335.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$176.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.79
|
| Rate for Payer: Health EOS Commercial |
$321.78
|
| Rate for Payer: HFN Commercial |
$335.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$335.92
|
| Rate for Payer: Quartz Beloit One Network |
$155.58
|
| Rate for Payer: Quartz Commercial |
$201.55
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$221.88
|
|
|
Primewire J 185cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 185cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 185cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.22
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 300cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.22
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 300cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 300cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.22
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 300cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
