|
SENSOR PAD BED SITTER II BED
|
Facility
|
OP
|
$478.00
|
|
| Hospital Charge Code |
2963767
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.84 |
| Max. Negotiated Rate |
$1,912.00 |
| Rate for Payer: Aetna Commercial |
$430.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Aetna Managed Medicare |
$133.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.34
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$439.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.49
|
| Rate for Payer: Health EOS Commercial |
$425.42
|
| Rate for Payer: HFN Commercial |
$439.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.50
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: NAPHCARE Commercial |
$286.80
|
| Rate for Payer: Preferred Network Access Commercial |
$439.76
|
| Rate for Payer: Quartz Beloit One Network |
$234.22
|
| Rate for Payer: Quartz Commercial |
$310.70
|
| Rate for Payer: Quartz Medicare Advantage |
$286.80
|
| Rate for Payer: The Alliance Commercial |
$1,912.00
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
SENSOR PAD SITTER II CHAIR ALARM 8309EL
|
Facility
|
IP
|
$582.00
|
|
| Hospital Charge Code |
2963691
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$285.18 |
| Max. Negotiated Rate |
$535.44 |
| Rate for Payer: Aetna Commercial |
$523.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$500.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$308.46
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$535.44
|
| Rate for Payer: Health EOS Commercial |
$517.98
|
| Rate for Payer: HFN Commercial |
$535.44
|
| Rate for Payer: Multiplan Commercial |
$465.60
|
| Rate for Payer: NAPHCARE Commercial |
$349.20
|
| Rate for Payer: Preferred Network Access Commercial |
$535.44
|
| Rate for Payer: Quartz Beloit One Network |
$285.18
|
| Rate for Payer: Quartz Commercial |
$349.20
|
| Rate for Payer: WEA Trust Commercial |
$320.10
|
| Rate for Payer: WPS Commercial |
$431.09
|
|
|
SENSOR PAD SITTER II CHAIR ALARM 8309EL
|
Facility
|
OP
|
$582.00
|
|
| Hospital Charge Code |
2963691
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$162.96 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Aetna Commercial |
$523.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$500.52
|
| Rate for Payer: Aetna Managed Medicare |
$162.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$378.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$291.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$279.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$308.46
|
| Rate for Payer: Cash Price |
$174.60
|
| Rate for Payer: Cigna Commercial |
$535.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$325.69
|
| Rate for Payer: Health EOS Commercial |
$517.98
|
| Rate for Payer: HFN Commercial |
$535.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$436.50
|
| Rate for Payer: Multiplan Commercial |
$465.60
|
| Rate for Payer: NAPHCARE Commercial |
$349.20
|
| Rate for Payer: Preferred Network Access Commercial |
$535.44
|
| Rate for Payer: Quartz Beloit One Network |
$285.18
|
| Rate for Payer: Quartz Commercial |
$378.30
|
| Rate for Payer: Quartz Medicare Advantage |
$349.20
|
| Rate for Payer: The Alliance Commercial |
$2,328.00
|
| Rate for Payer: WEA Trust Commercial |
$320.10
|
| Rate for Payer: WPS Commercial |
$431.09
|
|
|
SENSOR PEDIATRIC DISP
|
Facility
|
OP
|
$272.00
|
|
| Hospital Charge Code |
2963038
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.16 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$163.20
|
| Rate for Payer: The Alliance Commercial |
$1,088.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
SENSOR PEDIATRIC DISP
|
Facility
|
IP
|
$272.00
|
|
| Hospital Charge Code |
2963038
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Sensory Integration/15 Min Charges
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 97533 GP
|
| Hospital Charge Code |
2564915
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$78.68 |
| Max. Negotiated Rate |
$1,124.00 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Aetna Managed Medicare |
$78.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.25
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$182.65
|
| Rate for Payer: Quartz Medicare Advantage |
$168.60
|
| Rate for Payer: The Alliance Commercial |
$1,124.00
|
| Rate for Payer: United Healthcare PPO |
$210.75
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Sensory Integration/15 Min Charges
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 97533 GP
|
| Hospital Charge Code |
2564915
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$258.52 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.93
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$258.52
|
| Rate for Payer: Health EOS Commercial |
$250.09
|
| Rate for Payer: HFN Commercial |
$258.52
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: NAPHCARE Commercial |
$168.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.52
|
| Rate for Payer: Quartz Beloit One Network |
$137.69
|
| Rate for Payer: Quartz Commercial |
$168.60
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
|
Sensory Integration Charges ST
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
753739
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Sensory Integration Charges ST
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
753739
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare PPO |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
SENSORY PROFILE - COMPLETE
|
Facility
|
IP
|
$2,807.00
|
|
| Hospital Charge Code |
2973132
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,375.43 |
| Max. Negotiated Rate |
$2,582.44 |
| Rate for Payer: Aetna Commercial |
$2,526.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,487.71
|
| Rate for Payer: Cash Price |
$842.10
|
| Rate for Payer: Cigna Commercial |
$2,582.44
|
| Rate for Payer: Health EOS Commercial |
$2,498.23
|
| Rate for Payer: HFN Commercial |
$2,582.44
|
| Rate for Payer: Multiplan Commercial |
$2,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,582.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.43
|
| Rate for Payer: Quartz Commercial |
$1,684.20
|
| Rate for Payer: WEA Trust Commercial |
$1,543.85
|
| Rate for Payer: WPS Commercial |
$2,079.14
|
|
|
SENSORY PROFILE - COMPLETE
|
Facility
|
OP
|
$2,807.00
|
|
| Hospital Charge Code |
2973132
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$785.96 |
| Max. Negotiated Rate |
$11,228.00 |
| Rate for Payer: Aetna Commercial |
$2,526.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,414.02
|
| Rate for Payer: Aetna Managed Medicare |
$785.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,824.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,403.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,347.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,487.71
|
| Rate for Payer: Cash Price |
$842.10
|
| Rate for Payer: Cigna Commercial |
$2,582.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,570.80
|
| Rate for Payer: Health EOS Commercial |
$2,498.23
|
| Rate for Payer: HFN Commercial |
$2,582.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,105.25
|
| Rate for Payer: Multiplan Commercial |
$2,245.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,684.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,582.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,375.43
|
| Rate for Payer: Quartz Commercial |
$1,824.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,684.20
|
| Rate for Payer: The Alliance Commercial |
$11,228.00
|
| Rate for Payer: WEA Trust Commercial |
$1,543.85
|
| Rate for Payer: WPS Commercial |
$2,079.14
|
|
|
Sensory Stimulation Charge
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
750932
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Sensory Stimulation Charge
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
750932
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare PPO |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Separation by Gel Electrophoresis
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation by Gel Electrophoresis
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation by Gel Electrophoresis
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2778824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Separation & Identification
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Separation & Identification
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Separation & Identification
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2778820
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: United Healthcare PPO |
$213.75
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
SEPARATOR OPTICAL VISIPORT 12MMX100MM 176674P
|
Facility
|
OP
|
$506.00
|
|
| Hospital Charge Code |
2963115
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.68 |
| Max. Negotiated Rate |
$2,024.00 |
| Rate for Payer: Aetna Commercial |
$455.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.16
|
| Rate for Payer: Aetna Managed Medicare |
$141.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$328.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$253.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$242.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.18
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$465.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$283.16
|
| Rate for Payer: Health EOS Commercial |
$450.34
|
| Rate for Payer: HFN Commercial |
$465.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.50
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$465.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.94
|
| Rate for Payer: Quartz Commercial |
$328.90
|
| Rate for Payer: Quartz Medicare Advantage |
$303.60
|
| Rate for Payer: The Alliance Commercial |
$2,024.00
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$374.79
|
|
|
SEPARATOR OPTICAL VISIPORT 12MMX100MM 176674P
|
Facility
|
IP
|
$506.00
|
|
| Hospital Charge Code |
2963115
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$465.52 |
| Rate for Payer: Aetna Commercial |
$455.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$435.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.18
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cigna Commercial |
$465.52
|
| Rate for Payer: Health EOS Commercial |
$450.34
|
| Rate for Payer: HFN Commercial |
$465.52
|
| Rate for Payer: Multiplan Commercial |
$404.80
|
| Rate for Payer: NAPHCARE Commercial |
$303.60
|
| Rate for Payer: Preferred Network Access Commercial |
$465.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.94
|
| Rate for Payer: Quartz Commercial |
$303.60
|
| Rate for Payer: WEA Trust Commercial |
$278.30
|
| Rate for Payer: WPS Commercial |
$374.79
|
|
|
SEPRAFILM 3 X 5 [Med]
|
Facility
|
IP
|
$2,901.00
|
|
| Hospital Charge Code |
2974977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,421.49 |
| Max. Negotiated Rate |
$2,668.92 |
| Rate for Payer: Aetna Commercial |
$2,610.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,494.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,537.53
|
| Rate for Payer: Cash Price |
$870.30
|
| Rate for Payer: Cigna Commercial |
$2,668.92
|
| Rate for Payer: Health EOS Commercial |
$2,581.89
|
| Rate for Payer: HFN Commercial |
$2,668.92
|
| Rate for Payer: Multiplan Commercial |
$2,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,740.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,668.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.49
|
| Rate for Payer: Quartz Commercial |
$1,740.60
|
| Rate for Payer: WEA Trust Commercial |
$1,595.55
|
| Rate for Payer: WPS Commercial |
$2,148.77
|
|
|
SEPRAFILM 3 X 5 [Med]
|
Facility
|
OP
|
$2,901.00
|
|
| Hospital Charge Code |
2974977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$812.28 |
| Max. Negotiated Rate |
$11,604.00 |
| Rate for Payer: Aetna Commercial |
$2,610.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,494.86
|
| Rate for Payer: Aetna Managed Medicare |
$812.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,885.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,450.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,392.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,537.53
|
| Rate for Payer: Cash Price |
$870.30
|
| Rate for Payer: Cigna Commercial |
$2,668.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,623.40
|
| Rate for Payer: Health EOS Commercial |
$2,581.89
|
| Rate for Payer: HFN Commercial |
$2,668.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,175.75
|
| Rate for Payer: Multiplan Commercial |
$2,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,740.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,668.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.49
|
| Rate for Payer: Quartz Commercial |
$1,885.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,740.60
|
| Rate for Payer: The Alliance Commercial |
$11,604.00
|
| Rate for Payer: WEA Trust Commercial |
$1,595.55
|
| Rate for Payer: WPS Commercial |
$2,148.77
|
|
|
SEPTAL STAPLER ENTRIGUE ENTACT 601-00100S
|
Facility
|
OP
|
$2,365.00
|
|
| Hospital Charge Code |
3842759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$662.20 |
| Max. Negotiated Rate |
$9,460.00 |
| Rate for Payer: Aetna Commercial |
$2,128.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,033.90
|
| Rate for Payer: Aetna Managed Medicare |
$662.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,537.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,135.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,253.45
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cigna Commercial |
$2,175.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,323.45
|
| Rate for Payer: Health EOS Commercial |
$2,104.85
|
| Rate for Payer: HFN Commercial |
$2,175.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,773.75
|
| Rate for Payer: Multiplan Commercial |
$1,892.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,419.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,158.85
|
| Rate for Payer: Quartz Commercial |
$1,537.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,419.00
|
| Rate for Payer: The Alliance Commercial |
$9,460.00
|
| Rate for Payer: WEA Trust Commercial |
$1,300.75
|
| Rate for Payer: WPS Commercial |
$1,751.76
|
|
|
SEPTAL STAPLER ENTRIGUE ENTACT 601-00100S
|
Facility
|
IP
|
$2,365.00
|
|
| Hospital Charge Code |
3842759
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,158.85 |
| Max. Negotiated Rate |
$2,175.80 |
| Rate for Payer: Aetna Commercial |
$2,128.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,033.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,253.45
|
| Rate for Payer: Cash Price |
$709.50
|
| Rate for Payer: Cigna Commercial |
$2,175.80
|
| Rate for Payer: Health EOS Commercial |
$2,104.85
|
| Rate for Payer: HFN Commercial |
$2,175.80
|
| Rate for Payer: Multiplan Commercial |
$1,892.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,419.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,158.85
|
| Rate for Payer: Quartz Commercial |
$1,419.00
|
| Rate for Payer: WEA Trust Commercial |
$1,300.75
|
| Rate for Payer: WPS Commercial |
$1,751.76
|
|
