|
Sensory Integration Charges ST
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
753739
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare PPO |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Sensory Integration Charges ST
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
753739
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
SENSORY PROFILE - COMPLETE
|
Facility
|
OP
|
$2,807.00
|
|
| Hospital Charge Code |
2973132
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$785.96 |
| Max. Negotiated Rate |
$11,228.00 |
| Rate for Payer: Aetna Commercial |
$2,526.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.02
|
| Rate for Payer: Aetna Managed Medicare |
$785.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,824.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,403.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,347.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,487.71
|
| Rate for Payer: Cash Price |
$842.10
|
| Rate for Payer: Cigna Commercial |
$2,582.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,570.80
|
| Rate for Payer: Health EOS Commercial |
$2,498.23
|
| Rate for Payer: HFN Commercial |
$2,582.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,105.25
|
| Rate for Payer: Multiplan Commercial |
$2,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,582.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.43
|
| Rate for Payer: Quartz Commercial |
$1,824.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,684.20
|
| Rate for Payer: The Alliance Commercial |
$11,228.00
|
| Rate for Payer: WEA Trust Commercial |
$1,543.85
|
| Rate for Payer: WPS Commercial |
$2,079.14
|
|
|
SENSORY PROFILE - COMPLETE
|
Facility
|
IP
|
$2,807.00
|
|
| Hospital Charge Code |
2973132
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,375.43 |
| Max. Negotiated Rate |
$2,582.44 |
| Rate for Payer: Aetna Commercial |
$2,526.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,487.71
|
| Rate for Payer: Cash Price |
$842.10
|
| Rate for Payer: Cigna Commercial |
$2,582.44
|
| Rate for Payer: Health EOS Commercial |
$2,498.23
|
| Rate for Payer: HFN Commercial |
$2,582.44
|
| Rate for Payer: Multiplan Commercial |
$2,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,582.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.43
|
| Rate for Payer: Quartz Commercial |
$1,684.20
|
| Rate for Payer: WEA Trust Commercial |
$1,543.85
|
| Rate for Payer: WPS Commercial |
$2,079.14
|
|
|
Sensory Stimulation Charge
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
750932
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare PPO |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Sensory Stimulation Charge
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
750932
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Separation by Gel Electrophoresis
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation by Gel Electrophoresis
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation by Gel Electrophoresis
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation & Identification
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Separation & Identification
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: United Healthcare PPO |
$213.75
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Separation & Identification
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SEPARATOR OPTICAL VISIPORT 12MMX100MM 176674P
|
Facility
|
IP
|
$506.00
|
|
| Hospital Charge Code |
2963115
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$465.52 |
| Rate for Payer: Aetna Commercial |
$455.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.18
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$465.52
|
| Rate for Payer: Health EOS Commercial |
$450.34
|
| Rate for Payer: HFN Commercial |
$465.52
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$465.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.94
|
| Rate for Payer: Quartz Commercial |
$303.60
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$374.79
|
|
|
SEPARATOR OPTICAL VISIPORT 12MMX100MM 176674P
|
Facility
|
OP
|
$506.00
|
|
| Hospital Charge Code |
2963115
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.68 |
| Max. Negotiated Rate |
$2,024.00 |
| Rate for Payer: Aetna Commercial |
$455.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.16
|
| Rate for Payer: Aetna Managed Medicare |
$141.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$328.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$253.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$242.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.18
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$465.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$283.16
|
| Rate for Payer: Health EOS Commercial |
$450.34
|
| Rate for Payer: HFN Commercial |
$465.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.50
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$465.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.94
|
| Rate for Payer: Quartz Commercial |
$328.90
|
| Rate for Payer: Quartz Medicare Advantage |
$303.60
|
| Rate for Payer: The Alliance Commercial |
$2,024.00
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$374.79
|
|
|
SEPRAFILM 3 X 5 [Med]
|
Facility
|
OP
|
$2,901.00
|
|
| Hospital Charge Code |
2974977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$812.28 |
| Max. Negotiated Rate |
$11,604.00 |
| Rate for Payer: Aetna Commercial |
$2,610.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,494.86
|
| Rate for Payer: Aetna Managed Medicare |
$812.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,885.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,450.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,392.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,537.53
|
| Rate for Payer: Cash Price |
$870.30
|
| Rate for Payer: Cigna Commercial |
$2,668.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,623.40
|
| Rate for Payer: Health EOS Commercial |
$2,581.89
|
| Rate for Payer: HFN Commercial |
$2,668.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,175.75
|
| Rate for Payer: Multiplan Commercial |
$2,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,740.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,668.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.49
|
| Rate for Payer: Quartz Commercial |
$1,885.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,740.60
|
| Rate for Payer: The Alliance Commercial |
$11,604.00
|
| Rate for Payer: WEA Trust Commercial |
$1,595.55
|
| Rate for Payer: WPS Commercial |
$2,148.77
|
|
|
SEPRAFILM 3 X 5 [Med]
|
Facility
|
IP
|
$2,901.00
|
|
| Hospital Charge Code |
2974977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,421.49 |
| Max. Negotiated Rate |
$2,668.92 |
| Rate for Payer: Aetna Commercial |
$2,610.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,494.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,537.53
|
| Rate for Payer: Cash Price |
$870.30
|
| Rate for Payer: Cigna Commercial |
$2,668.92
|
| Rate for Payer: Health EOS Commercial |
$2,581.89
|
| Rate for Payer: HFN Commercial |
$2,668.92
|
| Rate for Payer: Multiplan Commercial |
$2,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,740.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,668.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.49
|
| Rate for Payer: Quartz Commercial |
$1,740.60
|
| Rate for Payer: WEA Trust Commercial |
$1,595.55
|
| Rate for Payer: WPS Commercial |
$2,148.77
|
|
|
SEPTAL STAPLER ENTRIGUE ENTACT 601-00100S
|
Facility
|
IP
|
$2,365.00
|
|
| Hospital Charge Code |
3842759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,158.85 |
| Max. Negotiated Rate |
$2,175.80 |
| Rate for Payer: Aetna Commercial |
$2,128.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,033.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,253.45
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cigna Commercial |
$2,175.80
|
| Rate for Payer: Health EOS Commercial |
$2,104.85
|
| Rate for Payer: HFN Commercial |
$2,175.80
|
| Rate for Payer: Multiplan Commercial |
$1,892.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,419.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,158.85
|
| Rate for Payer: Quartz Commercial |
$1,419.00
|
| Rate for Payer: WEA Trust Commercial |
$1,300.75
|
| Rate for Payer: WPS Commercial |
$1,751.76
|
|
|
SEPTAL STAPLER ENTRIGUE ENTACT 601-00100S
|
Facility
|
OP
|
$2,365.00
|
|
| Hospital Charge Code |
3842759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$662.20 |
| Max. Negotiated Rate |
$9,460.00 |
| Rate for Payer: Aetna Commercial |
$2,128.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,033.90
|
| Rate for Payer: Aetna Managed Medicare |
$662.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,537.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,135.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,253.45
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cigna Commercial |
$2,175.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,323.45
|
| Rate for Payer: Health EOS Commercial |
$2,104.85
|
| Rate for Payer: HFN Commercial |
$2,175.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,773.75
|
| Rate for Payer: Multiplan Commercial |
$1,892.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,419.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,158.85
|
| Rate for Payer: Quartz Commercial |
$1,537.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,419.00
|
| Rate for Payer: The Alliance Commercial |
$9,460.00
|
| Rate for Payer: WEA Trust Commercial |
$1,300.75
|
| Rate for Payer: WPS Commercial |
$1,751.76
|
|
|
SEPTIC ARTHRITIS WITH CC
|
Facility
|
IP
|
$32,388.00
|
|
|
Service Code
|
MSDRG 549
|
| Min. Negotiated Rate |
$11,650.51 |
| Max. Negotiated Rate |
$32,388.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,650.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,385.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,458.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,486.38
|
| Rate for Payer: Anthem Medicare Advantage |
$11,650.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,650.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,650.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,650.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,521.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,650.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,520.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,650.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,650.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,650.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,650.51
|
| Rate for Payer: NAPHCARE Commercial |
$17,475.76
|
| Rate for Payer: Quartz Medicare Advantage |
$11,650.51
|
| Rate for Payer: The Alliance Commercial |
$32,388.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,650.51
|
| Rate for Payer: United Healthcare PPO |
$18,311.32
|
| Rate for Payer: Wellcare Medicare |
$11,650.51
|
|
|
SEPTIC ARTHRITIS WITH MCC
|
Facility
|
IP
|
$52,158.00
|
|
|
Service Code
|
MSDRG 548
|
| Min. Negotiated Rate |
$18,761.78 |
| Max. Negotiated Rate |
$52,158.00 |
| Rate for Payer: Aetna Managed Medicare |
$18,761.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40,911.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,357.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29,792.10
|
| Rate for Payer: Anthem Medicare Advantage |
$18,761.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18,761.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18,761.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18,761.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,071.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18,761.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,021.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18,761.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18,761.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18,761.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18,761.78
|
| Rate for Payer: NAPHCARE Commercial |
$28,142.67
|
| Rate for Payer: Quartz Medicare Advantage |
$18,761.78
|
| Rate for Payer: The Alliance Commercial |
$52,158.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,761.78
|
| Rate for Payer: United Healthcare PPO |
$29,599.91
|
| Rate for Payer: Wellcare Medicare |
$18,761.78
|
|
|
SEPTIC ARTHRITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$25,404.00
|
|
|
Service Code
|
MSDRG 550
|
| Min. Negotiated Rate |
$9,138.24 |
| Max. Negotiated Rate |
$25,404.00 |
| Rate for Payer: Aetna Managed Medicare |
$9,138.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,301.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,794.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,055.76
|
| Rate for Payer: Anthem Medicare Advantage |
$9,138.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,138.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,138.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,138.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,603.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,138.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,955.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,138.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,138.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,138.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,138.24
|
| Rate for Payer: NAPHCARE Commercial |
$13,707.36
|
| Rate for Payer: Quartz Medicare Advantage |
$9,138.24
|
| Rate for Payer: The Alliance Commercial |
$25,404.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,138.24
|
| Rate for Payer: United Healthcare PPO |
$13,978.66
|
| Rate for Payer: Wellcare Medicare |
$9,138.24
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS
|
Facility
|
IP
|
$185,489.00
|
|
|
Service Code
|
MSDRG 870
|
| Min. Negotiated Rate |
$66,722.65 |
| Max. Negotiated Rate |
$185,489.00 |
| Rate for Payer: Aetna Managed Medicare |
$66,722.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$146,020.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111,923.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106,334.88
|
| Rate for Payer: Anthem Medicare Advantage |
$66,722.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$66,722.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$66,722.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$66,722.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118,041.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$66,722.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135,815.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66,722.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$66,722.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$66,722.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$66,722.65
|
| Rate for Payer: NAPHCARE Commercial |
$100,083.98
|
| Rate for Payer: Quartz Medicare Advantage |
$66,722.65
|
| Rate for Payer: The Alliance Commercial |
$185,489.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66,722.65
|
| Rate for Payer: United Healthcare PPO |
$105,734.15
|
| Rate for Payer: Wellcare Medicare |
$66,722.65
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC
|
Facility
|
IP
|
$53,030.00
|
|
|
Service Code
|
MSDRG 871
|
| Min. Negotiated Rate |
$19,075.45 |
| Max. Negotiated Rate |
$53,030.00 |
| Rate for Payer: Aetna Managed Medicare |
$19,075.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41,540.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,840.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30,250.44
|
| Rate for Payer: Anthem Medicare Advantage |
$19,075.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,075.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,075.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,075.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,580.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,075.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,660.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,075.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,075.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,075.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,075.45
|
| Rate for Payer: NAPHCARE Commercial |
$28,613.18
|
| Rate for Payer: Quartz Medicare Advantage |
$19,075.45
|
| Rate for Payer: The Alliance Commercial |
$53,030.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,075.45
|
| Rate for Payer: United Healthcare PPO |
$30,097.85
|
| Rate for Payer: Wellcare Medicare |
$19,075.45
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC
|
Facility
|
IP
|
$27,701.00
|
|
|
Service Code
|
MSDRG 872
|
| Min. Negotiated Rate |
$9,964.51 |
| Max. Negotiated Rate |
$27,701.00 |
| Rate for Payer: NAPHCARE Commercial |
$14,946.76
|
| Rate for Payer: Quartz Medicare Advantage |
$9,964.51
|
| Rate for Payer: The Alliance Commercial |
$27,701.00
|
| Rate for Payer: Aetna Managed Medicare |
$9,964.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,609.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,563.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,736.34
|
| Rate for Payer: Anthem Medicare Advantage |
$9,964.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,964.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,964.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,964.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,468.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,964.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,083.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,964.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,964.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,964.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,964.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,964.51
|
| Rate for Payer: United Healthcare PPO |
$15,634.91
|
| Rate for Payer: Wellcare Medicare |
$9,964.51
|
|
|
SEPTOPLASTY
|
Facility
|
OP
|
$4,238.00
|
|
| Hospital Charge Code |
2960370
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,186.64 |
| Max. Negotiated Rate |
$16,952.00 |
| Rate for Payer: Aetna Commercial |
$3,814.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,644.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,186.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,754.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,119.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,034.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,246.14
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$3,898.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,371.58
|
| Rate for Payer: Health EOS Commercial |
$3,771.82
|
| Rate for Payer: HFN Commercial |
$3,898.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,178.50
|
| Rate for Payer: Multiplan Commercial |
$3,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,542.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,898.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,076.62
|
| Rate for Payer: Quartz Commercial |
$2,754.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,542.80
|
| Rate for Payer: The Alliance Commercial |
$16,952.00
|
| Rate for Payer: WEA Trust Commercial |
$2,330.90
|
| Rate for Payer: WPS Commercial |
$3,139.09
|
|
