|
SCROTOPLASTY, SIMPLE
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2950486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
SCROTOPLASTY; SIMPLE
|
Facility
|
OP
|
$13,782.96
|
|
|
Service Code
|
CPT 55175
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,445.74 |
| Max. Negotiated Rate |
$13,782.96 |
| Rate for Payer: Aetna Managed Medicare |
$3,445.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,445.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,445.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,445.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,818.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,445.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,445.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,445.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,445.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,168.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,445.74
|
| Rate for Payer: The Alliance Commercial |
$13,782.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,445.74
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,445.74
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Aetna Managed Medicare |
$56.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.92
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$130.00
|
| Rate for Payer: Quartz Medicare Advantage |
$120.00
|
| Rate for Payer: The Alliance Commercial |
$800.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
SCRUB SURGICAL DURA-PREP 8630
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2963341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
SCRUB SURGICAL DURA-PREP 8630
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2963341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
SDH Complex Subunit B
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$320.32 |
| Max. Negotiated Rate |
$1,063.77 |
| Rate for Payer: Aetna Commercial |
$691.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$364.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$436.80
|
| Rate for Payer: Health EOS Commercial |
$662.48
|
| Rate for Payer: HFN Commercial |
$691.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,063.77
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: Preferred Network Access Commercial |
$691.60
|
| Rate for Payer: Quartz Beloit One Network |
$320.32
|
| Rate for Payer: Quartz Commercial |
$414.96
|
| Rate for Payer: The Alliance Commercial |
$364.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit B
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$669.76 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$436.80
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$436.80
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit B
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789662
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$1,205.40 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Aetna Managed Medicare |
$301.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,130.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$527.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$500.24
|
| Rate for Payer: Anthem Medicaid |
$301.35
|
| Rate for Payer: Anthem Medicare Advantage |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$301.35
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$301.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$407.39
|
| Rate for Payer: Dean Health Medicaid |
$301.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$301.35
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,121.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$301.35
|
| Rate for Payer: Managed Health Services Medicaid |
$313.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$301.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$301.35
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$452.02
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$301.35
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$473.20
|
| Rate for Payer: Quartz Medicare Advantage |
$301.35
|
| Rate for Payer: The Alliance Commercial |
$1,205.40
|
| Rate for Payer: United Healthcare Medicaid |
$301.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.35
|
| Rate for Payer: United Healthcare PPO |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: Wellcare Medicare |
$301.35
|
| Rate for Payer: WMAP Medicaid |
$301.35
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit C
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$320.32 |
| Max. Negotiated Rate |
$1,063.77 |
| Rate for Payer: Aetna Commercial |
$691.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$364.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$436.80
|
| Rate for Payer: Health EOS Commercial |
$662.48
|
| Rate for Payer: HFN Commercial |
$691.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,063.77
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: Preferred Network Access Commercial |
$691.60
|
| Rate for Payer: Quartz Beloit One Network |
$320.32
|
| Rate for Payer: Quartz Commercial |
$414.96
|
| Rate for Payer: The Alliance Commercial |
$364.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit C
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$1,205.40 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Aetna Managed Medicare |
$301.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,130.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$527.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$500.24
|
| Rate for Payer: Anthem Medicaid |
$301.35
|
| Rate for Payer: Anthem Medicare Advantage |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$301.35
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$301.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$407.39
|
| Rate for Payer: Dean Health Medicaid |
$301.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$301.35
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,121.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$301.35
|
| Rate for Payer: Managed Health Services Medicaid |
$313.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$301.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$301.35
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$452.02
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$301.35
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$473.20
|
| Rate for Payer: Quartz Medicare Advantage |
$301.35
|
| Rate for Payer: The Alliance Commercial |
$1,205.40
|
| Rate for Payer: United Healthcare Medicaid |
$301.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.35
|
| Rate for Payer: United Healthcare PPO |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: Wellcare Medicare |
$301.35
|
| Rate for Payer: WMAP Medicaid |
$301.35
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit C
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
3789661
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$669.76 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$436.80
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$436.80
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit D
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$320.32 |
| Max. Negotiated Rate |
$970.15 |
| Rate for Payer: Aetna Commercial |
$691.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$691.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$364.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$436.80
|
| Rate for Payer: Health EOS Commercial |
$662.48
|
| Rate for Payer: HFN Commercial |
$691.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$970.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$970.15
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: Preferred Network Access Commercial |
$691.60
|
| Rate for Payer: Quartz Beloit One Network |
$320.32
|
| Rate for Payer: Quartz Commercial |
$414.96
|
| Rate for Payer: The Alliance Commercial |
$364.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit D
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$274.83 |
| Max. Negotiated Rate |
$1,099.32 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Aetna Managed Medicare |
$274.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$480.95
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.22
|
| Rate for Payer: Anthem Medicaid |
$274.83
|
| Rate for Payer: Anthem Medicare Advantage |
$274.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$274.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$274.83
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$274.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$274.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$407.39
|
| Rate for Payer: Dean Health Medicaid |
$274.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$274.83
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,022.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$274.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$274.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$274.83
|
| Rate for Payer: Managed Health Services Medicaid |
$285.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$274.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$274.83
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$412.24
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$274.83
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$473.20
|
| Rate for Payer: Quartz Medicare Advantage |
$274.83
|
| Rate for Payer: The Alliance Commercial |
$1,099.32
|
| Rate for Payer: United Healthcare Medicaid |
$274.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$274.83
|
| Rate for Payer: United Healthcare PPO |
$546.00
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: Wellcare Medicare |
$274.83
|
| Rate for Payer: WMAP Medicaid |
$274.83
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SDH Complex Subunit D
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
CPT 81404
|
| Hospital Charge Code |
3789660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$669.76 |
| Rate for Payer: Aetna Commercial |
$655.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$385.84
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cigna Commercial |
$669.76
|
| Rate for Payer: Health EOS Commercial |
$647.92
|
| Rate for Payer: HFN Commercial |
$669.76
|
| Rate for Payer: Multiplan Commercial |
$582.40
|
| Rate for Payer: NAPHCARE Commercial |
$436.80
|
| Rate for Payer: Preferred Network Access Commercial |
$669.76
|
| Rate for Payer: Quartz Beloit One Network |
$356.72
|
| Rate for Payer: Quartz Commercial |
$436.80
|
| Rate for Payer: WEA Trust Commercial |
$400.40
|
| Rate for Payer: WPS Commercial |
$539.23
|
|
|
SEAL BIOPSY PORT UP TO 3FR STERILE AUR-BP
|
Facility
|
IP
|
$385.00
|
|
| Hospital Charge Code |
5384718
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.65 |
| Max. Negotiated Rate |
$354.20 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$231.00
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$231.00
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
SEAL BIOPSY PORT UP TO 3FR STERILE AUR-BP
|
Facility
|
OP
|
$385.00
|
|
| Hospital Charge Code |
5384718
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$1,540.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Aetna Managed Medicare |
$107.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.45
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.75
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$231.00
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$250.25
|
| Rate for Payer: Quartz Medicare Advantage |
$231.00
|
| Rate for Payer: The Alliance Commercial |
$1,540.00
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
SEALER AQUAMANTYS BIPOLAR 23-301-1
|
Facility
|
OP
|
$6,085.00
|
|
| Hospital Charge Code |
2965297
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,703.80 |
| Max. Negotiated Rate |
$24,340.00 |
| Rate for Payer: Aetna Commercial |
$5,476.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,233.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,703.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,955.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,042.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,920.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,225.05
|
| Rate for Payer: Cash Price |
$1,825.50
|
| Rate for Payer: Cigna Commercial |
$5,598.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,405.17
|
| Rate for Payer: Health EOS Commercial |
$5,415.65
|
| Rate for Payer: HFN Commercial |
$5,598.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,563.75
|
| Rate for Payer: Multiplan Commercial |
$4,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,598.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.65
|
| Rate for Payer: Quartz Commercial |
$3,955.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,651.00
|
| Rate for Payer: The Alliance Commercial |
$24,340.00
|
| Rate for Payer: WEA Trust Commercial |
$3,346.75
|
| Rate for Payer: WPS Commercial |
$4,507.16
|
|
|
SEALER AQUAMANTYS BIPOLAR 23-301-1
|
Facility
|
IP
|
$6,085.00
|
|
| Hospital Charge Code |
2965297
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,981.65 |
| Max. Negotiated Rate |
$5,598.20 |
| Rate for Payer: Aetna Commercial |
$5,476.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,233.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,225.05
|
| Rate for Payer: Cash Price |
$1,825.50
|
| Rate for Payer: Cigna Commercial |
$5,598.20
|
| Rate for Payer: Health EOS Commercial |
$5,415.65
|
| Rate for Payer: HFN Commercial |
$5,598.20
|
| Rate for Payer: Multiplan Commercial |
$4,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,651.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,598.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,981.65
|
| Rate for Payer: Quartz Commercial |
$3,651.00
|
| Rate for Payer: WEA Trust Commercial |
$3,346.75
|
| Rate for Payer: WPS Commercial |
$4,507.16
|
|
|
SEAL TRUCLEAR ELITE HYSTER0SCOPE 72205051
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
5496915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
SEAL TRUCLEAR ELITE HYSTER0SCOPE 72205051
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
5496915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Aetna Managed Medicare |
$42.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.94
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$97.50
|
| Rate for Payer: Quartz Medicare Advantage |
$90.00
|
| Rate for Payer: The Alliance Commercial |
$600.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
Securement Device - Central IV Dressing:
|
Facility
|
IP
|
$152.00
|
|
| Hospital Charge Code |
3000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$139.84 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
