|
Sodium Level Urine
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633612
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Aetna Managed Medicare |
$5.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.40
|
| Rate for Payer: Anthem Medicaid |
$5.23
|
| Rate for Payer: Anthem Medicare Advantage |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.06
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.09
|
| Rate for Payer: Dean Health Medicaid |
$5.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.06
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.06
|
| Rate for Payer: Managed Health Services Medicaid |
$5.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.06
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.59
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.23
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$50.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5.06
|
| Rate for Payer: The Alliance Commercial |
$20.24
|
| Rate for Payer: United Healthcare Medicaid |
$5.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.06
|
| Rate for Payer: United Healthcare PPO |
$57.75
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: Wellcare Medicare |
$5.06
|
| Rate for Payer: WMAP Medicaid |
$5.23
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Sodium Level Urine
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633612
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.73 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.20
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$46.20
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Sodium Tetradecyl 1% 2ml vial [Med]
|
Facility
|
OP
|
$931.00
|
|
| Hospital Charge Code |
2974982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.68 |
| Max. Negotiated Rate |
$3,724.00 |
| Rate for Payer: Aetna Commercial |
$837.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$800.66
|
| Rate for Payer: Aetna Managed Medicare |
$260.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$605.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$465.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$493.43
|
| Rate for Payer: Cash Price |
$279.30
|
| Rate for Payer: Cigna Commercial |
$856.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$520.99
|
| Rate for Payer: Health EOS Commercial |
$828.59
|
| Rate for Payer: HFN Commercial |
$856.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$698.25
|
| Rate for Payer: Multiplan Commercial |
$744.80
|
| Rate for Payer: NAPHCARE Commercial |
$558.60
|
| Rate for Payer: Preferred Network Access Commercial |
$856.52
|
| Rate for Payer: Quartz Beloit One Network |
$456.19
|
| Rate for Payer: Quartz Commercial |
$605.15
|
| Rate for Payer: Quartz Medicare Advantage |
$558.60
|
| Rate for Payer: The Alliance Commercial |
$3,724.00
|
| Rate for Payer: WEA Trust Commercial |
$512.05
|
| Rate for Payer: WPS Commercial |
$689.59
|
|
|
Sodium Tetradecyl 1% 2ml vial [Med]
|
Facility
|
IP
|
$931.00
|
|
| Hospital Charge Code |
2974982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$456.19 |
| Max. Negotiated Rate |
$856.52 |
| Rate for Payer: Aetna Commercial |
$837.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$800.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$493.43
|
| Rate for Payer: Cash Price |
$279.30
|
| Rate for Payer: Cigna Commercial |
$856.52
|
| Rate for Payer: Health EOS Commercial |
$828.59
|
| Rate for Payer: HFN Commercial |
$856.52
|
| Rate for Payer: Multiplan Commercial |
$744.80
|
| Rate for Payer: NAPHCARE Commercial |
$558.60
|
| Rate for Payer: Preferred Network Access Commercial |
$856.52
|
| Rate for Payer: Quartz Beloit One Network |
$456.19
|
| Rate for Payer: Quartz Commercial |
$558.60
|
| Rate for Payer: WEA Trust Commercial |
$512.05
|
| Rate for Payer: WPS Commercial |
$689.59
|
|
|
SOFT ANCHOR FIBERTAK 2.6MM KNOTLESS RC SP 1.7 FIBER TAPE LOOP (BLACK/BLUE) #2 SUTURE (BLUE/BLACK) AR
|
Facility
|
IP
|
$3,947.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6174119
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,934.03 |
| Max. Negotiated Rate |
$3,631.24 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,368.20
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
SOFT ANCHOR FIBERTAK 2.6MM KNOTLESS RC SP 1.7 FIBER TAPE LOOP (BLACK/BLUE) #2 SUTURE (BLUE/BLACK) AR
|
Facility
|
OP
|
$3,947.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6174119
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,105.16 |
| Max. Negotiated Rate |
$15,788.00 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,105.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,565.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,973.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,894.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,208.74
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,960.25
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,565.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,368.20
|
| Rate for Payer: The Alliance Commercial |
$15,788.00
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
SOFT ANCHOR FIBERTAK 2.6MM KNOTLESS RC SP 1.7 FIBER TAPE LOOP (BLUE) #2 SUTURE (WHITE/BLACK) AR-3653
|
Facility
|
OP
|
$3,947.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6174118
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,105.16 |
| Max. Negotiated Rate |
$15,788.00 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,105.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,565.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,973.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,894.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,208.74
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,960.25
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,565.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,368.20
|
| Rate for Payer: The Alliance Commercial |
$15,788.00
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
SOFT ANCHOR FIBERTAK 2.6MM KNOTLESS RC SP 1.7 FIBER TAPE LOOP (BLUE) #2 SUTURE (WHITE/BLACK) AR-3653
|
Facility
|
IP
|
$3,947.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6174118
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,934.03 |
| Max. Negotiated Rate |
$3,631.24 |
| Rate for Payer: Aetna Commercial |
$3,552.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.91
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,631.24
|
| Rate for Payer: Health EOS Commercial |
$3,512.83
|
| Rate for Payer: HFN Commercial |
$3,631.24
|
| Rate for Payer: Multiplan Commercial |
$3,157.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,934.03
|
| Rate for Payer: Quartz Commercial |
$2,368.20
|
| Rate for Payer: WEA Trust Commercial |
$2,170.85
|
| Rate for Payer: WPS Commercial |
$2,923.54
|
|
|
Soft Interface below Knee Se L2820
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS L2820
|
| Hospital Charge Code |
4718607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Aetna Managed Medicare |
$70.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.02
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$163.80
|
| Rate for Payer: Quartz Medicare Advantage |
$151.20
|
| Rate for Payer: The Alliance Commercial |
$1,008.00
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Soft Interface below Knee Se L2820
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS L2820
|
| Hospital Charge Code |
4718607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$123.48 |
| Max. Negotiated Rate |
$231.84 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$151.20
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Soft Interface below Knee Se L2820
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS L2820
|
| Hospital Charge Code |
4718607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$110.88 |
| Max. Negotiated Rate |
$287.73 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$239.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$126.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.20
|
| Rate for Payer: Health EOS Commercial |
$229.32
|
| Rate for Payer: HFN Commercial |
$239.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.73
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: Preferred Network Access Commercial |
$239.40
|
| Rate for Payer: Quartz Beloit One Network |
$110.88
|
| Rate for Payer: Quartz Commercial |
$143.64
|
| Rate for Payer: The Alliance Commercial |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
SOFT TISSUE PROCEDURES WITH CC
|
Facility
|
IP
|
$46,466.00
|
|
|
Service Code
|
MSDRG 501
|
| Min. Negotiated Rate |
$16,714.27 |
| Max. Negotiated Rate |
$46,466.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,714.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36,505.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,980.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,583.72
|
| Rate for Payer: Anthem Medicare Advantage |
$16,714.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,714.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,714.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,714.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,510.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,714.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,846.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,714.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,714.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,714.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,714.27
|
| Rate for Payer: NAPHCARE Commercial |
$25,071.40
|
| Rate for Payer: Quartz Medicare Advantage |
$16,714.27
|
| Rate for Payer: The Alliance Commercial |
$46,466.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,714.27
|
| Rate for Payer: United Healthcare PPO |
$26,349.66
|
| Rate for Payer: Wellcare Medicare |
$16,714.27
|
|
|
SOFT TISSUE PROCEDURES WITH MCC
|
Facility
|
IP
|
$86,533.00
|
|
|
Service Code
|
MSDRG 500
|
| Min. Negotiated Rate |
$31,127.12 |
| Max. Negotiated Rate |
$86,533.00 |
| Rate for Payer: Aetna Managed Medicare |
$31,127.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67,975.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52,102.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49,500.72
|
| Rate for Payer: Anthem Medicare Advantage |
$31,127.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31,127.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31,127.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$31,127.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54,950.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$31,127.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63,234.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31,127.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31,127.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$31,127.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$31,127.12
|
| Rate for Payer: NAPHCARE Commercial |
$46,690.68
|
| Rate for Payer: Quartz Medicare Advantage |
$31,127.12
|
| Rate for Payer: The Alliance Commercial |
$86,533.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31,127.12
|
| Rate for Payer: United Healthcare PPO |
$49,228.95
|
| Rate for Payer: Wellcare Medicare |
$31,127.12
|
|
|
SOFT TISSUE PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$37,081.00
|
|
|
Service Code
|
MSDRG 502
|
| Min. Negotiated Rate |
$13,338.44 |
| Max. Negotiated Rate |
$37,081.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,338.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,952.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,191.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,083.64
|
| Rate for Payer: Anthem Medicare Advantage |
$13,338.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,338.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,338.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,338.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,404.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,338.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,962.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,338.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,338.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,338.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,338.44
|
| Rate for Payer: NAPHCARE Commercial |
$20,007.66
|
| Rate for Payer: Quartz Medicare Advantage |
$13,338.44
|
| Rate for Payer: The Alliance Commercial |
$37,081.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,338.44
|
| Rate for Payer: United Healthcare PPO |
$20,990.77
|
| Rate for Payer: Wellcare Medicare |
$13,338.44
|
|
|
SOL.0.45% S.C.WATER 1000ML
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2962801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
SOL.0.45% S.C.WATER 1000ML
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2962801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
SOL.0.45%S.C.WATER 500 7985-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963806
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
SOL.0.45%S.C.WATER 500 7985-03
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2963806
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Aetna Managed Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.03
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.50
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$22.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20.40
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
SOL.0.9%S.C.IRRIG 3000 NDC 0409-7972-08
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2963791
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SOL.0.9%S.C.IRRIG 3000 NDC 0409-7972-08
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2963791
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
SOL.10%D/W 1000 BAG
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2963854
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SOL.10%D/W 1000 BAG
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2963854
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SOL.250 5%D/WATER 152202
|
Facility
|
OP
|
$106.00
|
|
| Hospital Charge Code |
3000487
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$424.00 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.32
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$63.60
|
| Rate for Payer: The Alliance Commercial |
$424.00
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
SOL.250 5%D/WATER 152202
|
Facility
|
IP
|
$106.00
|
|
| Hospital Charge Code |
3000487
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
SOL 5%D/45%SOD CHL 500 7926-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963808
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
