|
SCREW/WASHER 2.7MM DIA X 10MM L TI STERILE 285210SND
|
Facility
|
OP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,242.26 |
| Max. Negotiated Rate |
$4,081.71 |
| Rate for Payer: Aetna Commercial |
$3,992.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,815.51
|
| Rate for Payer: Aetna Managed Medicare |
$1,242.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,883.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,218.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,129.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,351.42
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$4,081.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,482.81
|
| Rate for Payer: Health EOS Commercial |
$3,948.61
|
| Rate for Payer: HFN Commercial |
$4,081.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,327.48
|
| Rate for Payer: Multiplan Commercial |
$3,549.31
|
| Rate for Payer: NAPHCARE Commercial |
$2,661.98
|
| Rate for Payer: Preferred Network Access Commercial |
$4,081.71
|
| Rate for Payer: Quartz Beloit One Network |
$2,173.95
|
| Rate for Payer: Quartz Commercial |
$2,883.82
|
| Rate for Payer: Quartz Medicare Advantage |
$2,661.98
|
| Rate for Payer: The Alliance Commercial |
$2,218.32
|
| Rate for Payer: WEA Trust Commercial |
$2,440.15
|
| Rate for Payer: WPS Commercial |
$3,286.10
|
|
|
SCREW/WASHER 2.7MM DIA X 14MM L TI STERILE 285214SND
|
Facility
|
OP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,242.26 |
| Max. Negotiated Rate |
$4,081.71 |
| Rate for Payer: Aetna Commercial |
$3,992.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,815.51
|
| Rate for Payer: Aetna Managed Medicare |
$1,242.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,883.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,218.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,129.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,351.42
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$4,081.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,482.81
|
| Rate for Payer: Health EOS Commercial |
$3,948.61
|
| Rate for Payer: HFN Commercial |
$4,081.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,327.48
|
| Rate for Payer: Multiplan Commercial |
$3,549.31
|
| Rate for Payer: NAPHCARE Commercial |
$2,661.98
|
| Rate for Payer: Preferred Network Access Commercial |
$4,081.71
|
| Rate for Payer: Quartz Beloit One Network |
$2,173.95
|
| Rate for Payer: Quartz Commercial |
$2,883.82
|
| Rate for Payer: Quartz Medicare Advantage |
$2,661.98
|
| Rate for Payer: The Alliance Commercial |
$2,218.32
|
| Rate for Payer: WEA Trust Commercial |
$2,440.15
|
| Rate for Payer: WPS Commercial |
$3,286.10
|
|
|
SCREW/WASHER 2.7MM DIA X 14MM L TI STERILE 285214SND
|
Facility
|
IP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,173.95 |
| Max. Negotiated Rate |
$4,081.71 |
| Rate for Payer: Aetna Commercial |
$3,992.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,815.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,351.42
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$4,081.71
|
| Rate for Payer: Health EOS Commercial |
$3,948.61
|
| Rate for Payer: HFN Commercial |
$4,081.71
|
| Rate for Payer: Multiplan Commercial |
$3,549.31
|
| Rate for Payer: Preferred Network Access Commercial |
$4,081.71
|
| Rate for Payer: Quartz Beloit One Network |
$2,173.95
|
| Rate for Payer: Quartz Commercial |
$2,661.98
|
| Rate for Payer: WEA Trust Commercial |
$2,440.15
|
| Rate for Payer: WPS Commercial |
$3,286.10
|
|
|
SCROTAL EXPLORATION
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960366
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
SCROTAL EXPLORATION
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960366
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
SCROTOPLASTY, SIMPLE
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2950486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SCROTOPLASTY, SIMPLE
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2950486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SCROTOPLASTY; SIMPLE
|
Facility
|
OP
|
$14,838.60
|
|
|
Service Code
|
CPT 55175
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,709.65 |
| Max. Negotiated Rate |
$14,838.60 |
| Rate for Payer: Aetna Managed Medicare |
$3,709.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,709.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,799.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,709.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,709.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,709.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,709.65
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.65
|
| Rate for Payer: The Alliance Commercial |
$14,838.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,709.65
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,709.65
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$35.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.94
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$76.75
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$76.75
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
SCRUB SURGICAL DURA-PREP 8630
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2963341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
SCRUB SURGICAL DURA-PREP 8630
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2963341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
SDH Complex Subunit B
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$1,378.98 |
| Rate for Payer: Aetna Commercial |
$719.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$313.40
|
| Rate for Payer: Anthem Medicare Advantage |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$313.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$719.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$378.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.40
|
| Rate for Payer: Health EOS Commercial |
$688.98
|
| Rate for Payer: HFN Commercial |
$719.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,106.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,106.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$313.40
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$470.11
|
| Rate for Payer: Preferred Network Access Commercial |
$719.26
|
| Rate for Payer: Quartz Beloit One Network |
$333.13
|
| Rate for Payer: Quartz Commercial |
$431.56
|
| Rate for Payer: Quartz Medicare Advantage |
$313.40
|
| Rate for Payer: The Alliance Commercial |
$1,237.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.40
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$1,378.98
|
|
|
SDH Complex Subunit B
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$1,253.62 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$313.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,175.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$548.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.25
|
| Rate for Payer: Anthem Medicare Advantage |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$313.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$313.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$423.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$313.40
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,165.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$313.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$313.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$313.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$313.40
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$470.11
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$492.13
|
| Rate for Payer: Quartz Medicare Advantage |
$313.40
|
| Rate for Payer: The Alliance Commercial |
$1,253.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.40
|
| Rate for Payer: United Healthcare PPO |
$567.84
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: Wellcare Medicare |
$313.40
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit B
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$696.55 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$454.27
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit C
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$1,378.98 |
| Rate for Payer: Aetna Commercial |
$719.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$313.40
|
| Rate for Payer: Anthem Medicare Advantage |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$313.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$719.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$378.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.40
|
| Rate for Payer: Health EOS Commercial |
$688.98
|
| Rate for Payer: HFN Commercial |
$719.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,106.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,106.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$313.40
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$470.11
|
| Rate for Payer: Preferred Network Access Commercial |
$719.26
|
| Rate for Payer: Quartz Beloit One Network |
$333.13
|
| Rate for Payer: Quartz Commercial |
$431.56
|
| Rate for Payer: Quartz Medicare Advantage |
$313.40
|
| Rate for Payer: The Alliance Commercial |
$1,237.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.40
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$1,378.98
|
|
|
SDH Complex Subunit C
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$313.40 |
| Max. Negotiated Rate |
$1,253.62 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$313.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,175.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$548.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.25
|
| Rate for Payer: Anthem Medicare Advantage |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$313.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$313.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$313.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$423.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$313.40
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,165.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$313.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$313.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$313.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$313.40
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$470.11
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$492.13
|
| Rate for Payer: Quartz Medicare Advantage |
$313.40
|
| Rate for Payer: The Alliance Commercial |
$1,253.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$313.40
|
| Rate for Payer: United Healthcare PPO |
$567.84
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: Wellcare Medicare |
$313.40
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit C
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$696.55 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$454.27
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit D
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$696.55 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$454.27
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit D
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$285.82 |
| Max. Negotiated Rate |
$1,143.29 |
| Rate for Payer: Aetna Commercial |
$681.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$285.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,071.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$500.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$474.47
|
| Rate for Payer: Anthem Medicare Advantage |
$285.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$401.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$285.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$285.82
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$696.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$285.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$423.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$285.82
|
| Rate for Payer: Health EOS Commercial |
$673.84
|
| Rate for Payer: HFN Commercial |
$696.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$285.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$285.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$285.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$285.82
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$428.73
|
| Rate for Payer: Preferred Network Access Commercial |
$696.55
|
| Rate for Payer: Quartz Beloit One Network |
$370.99
|
| Rate for Payer: Quartz Commercial |
$492.13
|
| Rate for Payer: Quartz Medicare Advantage |
$285.82
|
| Rate for Payer: The Alliance Commercial |
$1,143.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$285.82
|
| Rate for Payer: United Healthcare PPO |
$567.84
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: Wellcare Medicare |
$285.82
|
| Rate for Payer: WPS Commercial |
$560.78
|
|
|
SDH Complex Subunit D
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$285.82 |
| Max. Negotiated Rate |
$1,257.62 |
| Rate for Payer: Aetna Commercial |
$719.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$651.12
|
| Rate for Payer: Aetna Managed Medicare |
$285.82
|
| Rate for Payer: Anthem Medicare Advantage |
$285.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$285.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$285.82
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$719.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$378.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.82
|
| Rate for Payer: Health EOS Commercial |
$688.98
|
| Rate for Payer: HFN Commercial |
$719.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,008.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,008.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$285.82
|
| Rate for Payer: Multiplan Commercial |
$605.70
|
| Rate for Payer: NAPHCARE Commercial |
$428.73
|
| Rate for Payer: Preferred Network Access Commercial |
$719.26
|
| Rate for Payer: Quartz Beloit One Network |
$333.13
|
| Rate for Payer: Quartz Commercial |
$431.56
|
| Rate for Payer: Quartz Medicare Advantage |
$285.82
|
| Rate for Payer: The Alliance Commercial |
$1,129.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$285.82
|
| Rate for Payer: WEA Trust Commercial |
$416.42
|
| Rate for Payer: WPS Commercial |
$1,257.62
|
|
|
SEALANT
|
Facility
|
OP
|
$27.52
|
|
|
Service Code
|
EAPG 00372
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$27.52 |
| Rate for Payer: Anthem Medicaid |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.46
|
| Rate for Payer: Dean Health Medicaid |
$26.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.46
|
| Rate for Payer: Managed Health Services Medicaid |
$27.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.46
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.46
|
| Rate for Payer: United Healthcare Medicaid |
$26.46
|
|
|
SEAL BIOPSY PORT UP TO 3FR STERILE AUR-BP
|
Facility
|
IP
|
$385.00
|
|
| Hospital Charge Code |
5384718
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.20 |
| Max. Negotiated Rate |
$368.37 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.21
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$368.37
|
| Rate for Payer: Health EOS Commercial |
$356.36
|
| Rate for Payer: HFN Commercial |
$368.37
|
| Rate for Payer: Multiplan Commercial |
$320.32
|
| Rate for Payer: Preferred Network Access Commercial |
$368.37
|
| Rate for Payer: Quartz Beloit One Network |
$196.20
|
| Rate for Payer: Quartz Commercial |
$240.24
|
| Rate for Payer: WEA Trust Commercial |
$220.22
|
| Rate for Payer: WPS Commercial |
$296.57
|
|
