|
SPACER UNIVERSAL REVERS 36 +6 AR-9555-06
|
Facility
IP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,553.88 |
| Max. Negotiated Rate |
$4,795.04 |
| Rate for Payer: Aetna Commercial |
$4,690.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.36
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,795.04
|
| Rate for Payer: Health EOS Commercial |
$4,638.68
|
| Rate for Payer: HFN Commercial |
$4,795.04
|
| Rate for Payer: Multiplan Commercial |
$4,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,553.88
|
| Rate for Payer: Quartz Commercial |
$3,127.20
|
| Rate for Payer: WEA Trust Commercial |
$2,866.60
|
| Rate for Payer: WPS Commercial |
$3,860.53
|
|
|
SPACER UNIVERSAL REVERS 36 +6 AR-9555-06
|
Facility
OP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.36 |
| Max. Negotiated Rate |
$4,795.04 |
| Rate for Payer: Aetna Commercial |
$4,690.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,482.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,459.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,387.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,501.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.36
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,795.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,916.64
|
| Rate for Payer: Health EOS Commercial |
$4,638.68
|
| Rate for Payer: HFN Commercial |
$4,795.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,909.00
|
| Rate for Payer: Multiplan Commercial |
$4,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,553.88
|
| Rate for Payer: Quartz Commercial |
$3,387.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,127.20
|
| Rate for Payer: WEA Trust Commercial |
$2,866.60
|
| Rate for Payer: WPS Commercial |
$3,860.53
|
|
|
SPACER UNIVERSAL REVERSE 39 +15MM AR-9505-15
|
Facility
IP
|
$51,270.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,122.30 |
| Max. Negotiated Rate |
$47,168.40 |
| Rate for Payer: Aetna Commercial |
$46,143.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,173.10
|
| Rate for Payer: Cash Price |
$15,381.00
|
| Rate for Payer: Cigna Commercial |
$47,168.40
|
| Rate for Payer: Health EOS Commercial |
$45,630.30
|
| Rate for Payer: HFN Commercial |
$47,168.40
|
| Rate for Payer: Multiplan Commercial |
$41,016.00
|
| Rate for Payer: NAPHCARE Commercial |
$30,762.00
|
| Rate for Payer: Preferred Network Access Commercial |
$47,168.40
|
| Rate for Payer: Quartz Beloit One Network |
$25,122.30
|
| Rate for Payer: Quartz Commercial |
$30,762.00
|
| Rate for Payer: WEA Trust Commercial |
$28,198.50
|
| Rate for Payer: WPS Commercial |
$37,975.69
|
|
|
SPACER UNIVERSAL REVERSE 39 +15MM AR-9505-15
|
Facility
OP
|
$51,270.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,355.60 |
| Max. Negotiated Rate |
$47,168.40 |
| Rate for Payer: Aetna Commercial |
$46,143.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44,092.20
|
| Rate for Payer: Aetna Managed Medicare |
$14,355.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,325.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,635.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,609.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27,173.10
|
| Rate for Payer: Cash Price |
$15,381.00
|
| Rate for Payer: Cigna Commercial |
$47,168.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,690.69
|
| Rate for Payer: Health EOS Commercial |
$45,630.30
|
| Rate for Payer: HFN Commercial |
$47,168.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,452.50
|
| Rate for Payer: Multiplan Commercial |
$41,016.00
|
| Rate for Payer: NAPHCARE Commercial |
$30,762.00
|
| Rate for Payer: Preferred Network Access Commercial |
$47,168.40
|
| Rate for Payer: Quartz Beloit One Network |
$25,122.30
|
| Rate for Payer: Quartz Commercial |
$33,325.50
|
| Rate for Payer: Quartz Medicare Advantage |
$30,762.00
|
| Rate for Payer: WEA Trust Commercial |
$28,198.50
|
| Rate for Payer: WPS Commercial |
$37,975.69
|
|
|
SPACER UNIVERSAL REVERSE 39 +6MM AR-9505-06
|
Facility
IP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5264988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,553.88 |
| Max. Negotiated Rate |
$4,795.04 |
| Rate for Payer: Aetna Commercial |
$4,690.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.36
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,795.04
|
| Rate for Payer: Health EOS Commercial |
$4,638.68
|
| Rate for Payer: HFN Commercial |
$4,795.04
|
| Rate for Payer: Multiplan Commercial |
$4,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,553.88
|
| Rate for Payer: Quartz Commercial |
$3,127.20
|
| Rate for Payer: WEA Trust Commercial |
$2,866.60
|
| Rate for Payer: WPS Commercial |
$3,860.53
|
|
|
SPACER UNIVERSAL REVERSE 39 +6MM AR-9505-06
|
Facility
OP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5264988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.36 |
| Max. Negotiated Rate |
$4,795.04 |
| Rate for Payer: Aetna Commercial |
$4,690.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,482.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,459.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,387.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,501.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.36
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,795.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,916.64
|
| Rate for Payer: Health EOS Commercial |
$4,638.68
|
| Rate for Payer: HFN Commercial |
$4,795.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,909.00
|
| Rate for Payer: Multiplan Commercial |
$4,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,553.88
|
| Rate for Payer: Quartz Commercial |
$3,387.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,127.20
|
| Rate for Payer: WEA Trust Commercial |
$2,866.60
|
| Rate for Payer: WPS Commercial |
$3,860.53
|
|
|
SPACER UNIVERSAL REVERSE 39 +9MM AR-9505-09
|
Facility
IP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5416051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.88 |
| Max. Negotiated Rate |
$4,611.04 |
| Rate for Payer: Aetna Commercial |
$4,510.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.36
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,611.04
|
| Rate for Payer: Health EOS Commercial |
$4,460.68
|
| Rate for Payer: HFN Commercial |
$4,611.04
|
| Rate for Payer: Multiplan Commercial |
$4,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.88
|
| Rate for Payer: Quartz Commercial |
$3,007.20
|
| Rate for Payer: WEA Trust Commercial |
$2,756.60
|
| Rate for Payer: WPS Commercial |
$3,712.39
|
|
|
SPACER UNIVERSAL REVERSE 39 +9MM AR-9505-09
|
Facility
OP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5416051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,403.36 |
| Max. Negotiated Rate |
$4,611.04 |
| Rate for Payer: Aetna Commercial |
$4,510.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,310.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,403.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,257.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,506.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,405.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.36
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,611.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,804.72
|
| Rate for Payer: Health EOS Commercial |
$4,460.68
|
| Rate for Payer: HFN Commercial |
$4,611.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,759.00
|
| Rate for Payer: Multiplan Commercial |
$4,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.88
|
| Rate for Payer: Quartz Commercial |
$3,257.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,007.20
|
| Rate for Payer: WEA Trust Commercial |
$2,756.60
|
| Rate for Payer: WPS Commercial |
$3,712.39
|
|
|
SPACER UNIVERSAL REVERSE 42 +6 AR-9550-06
|
Facility
IP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.88 |
| Max. Negotiated Rate |
$4,611.04 |
| Rate for Payer: Aetna Commercial |
$4,510.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.36
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,611.04
|
| Rate for Payer: Health EOS Commercial |
$4,460.68
|
| Rate for Payer: HFN Commercial |
$4,611.04
|
| Rate for Payer: Multiplan Commercial |
$4,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.88
|
| Rate for Payer: Quartz Commercial |
$3,007.20
|
| Rate for Payer: WEA Trust Commercial |
$2,756.60
|
| Rate for Payer: WPS Commercial |
$3,712.39
|
|
|
SPACER UNIVERSAL REVERSE 42 +6 AR-9550-06
|
Facility
OP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,403.36 |
| Max. Negotiated Rate |
$4,611.04 |
| Rate for Payer: Aetna Commercial |
$4,510.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,310.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,403.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,257.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,506.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,405.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,656.36
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,611.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,804.72
|
| Rate for Payer: Health EOS Commercial |
$4,460.68
|
| Rate for Payer: HFN Commercial |
$4,611.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,759.00
|
| Rate for Payer: Multiplan Commercial |
$4,009.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,007.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,611.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,455.88
|
| Rate for Payer: Quartz Commercial |
$3,257.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,007.20
|
| Rate for Payer: WEA Trust Commercial |
$2,756.60
|
| Rate for Payer: WPS Commercial |
$3,712.39
|
|
|
SPATULA PROBE PLUS #EPS02
|
Facility
OP
|
$1,453.00
|
|
| Hospital Charge Code |
2962913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$406.84 |
| Max. Negotiated Rate |
$5,812.00 |
| Rate for Payer: Aetna Commercial |
$1,307.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,249.58
|
| Rate for Payer: Aetna Managed Medicare |
$406.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$697.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$770.09
|
| Rate for Payer: Cash Price |
$435.90
|
| Rate for Payer: Cigna Commercial |
$1,336.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$813.10
|
| Rate for Payer: Health EOS Commercial |
$1,293.17
|
| Rate for Payer: HFN Commercial |
$1,336.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,089.75
|
| Rate for Payer: Multiplan Commercial |
$1,162.40
|
| Rate for Payer: NAPHCARE Commercial |
$871.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,336.76
|
| Rate for Payer: Quartz Beloit One Network |
$711.97
|
| Rate for Payer: Quartz Commercial |
$944.45
|
| Rate for Payer: Quartz Medicare Advantage |
$871.80
|
| Rate for Payer: The Alliance Commercial |
$5,812.00
|
| Rate for Payer: WEA Trust Commercial |
$799.15
|
| Rate for Payer: WPS Commercial |
$1,076.24
|
|
|
SPATULA PROBE PLUS #EPS02
|
Facility
IP
|
$1,453.00
|
|
| Hospital Charge Code |
2962913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$711.97 |
| Max. Negotiated Rate |
$1,336.76 |
| Rate for Payer: Aetna Commercial |
$1,307.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$770.09
|
| Rate for Payer: Cash Price |
$435.90
|
| Rate for Payer: Cigna Commercial |
$1,336.76
|
| Rate for Payer: Health EOS Commercial |
$1,293.17
|
| Rate for Payer: HFN Commercial |
$1,336.76
|
| Rate for Payer: Multiplan Commercial |
$1,162.40
|
| Rate for Payer: NAPHCARE Commercial |
$871.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,336.76
|
| Rate for Payer: Quartz Beloit One Network |
$711.97
|
| Rate for Payer: Quartz Commercial |
$871.80
|
| Rate for Payer: WEA Trust Commercial |
$799.15
|
| Rate for Payer: WPS Commercial |
$1,076.24
|
|
|
SpCO
|
Facility
IP
|
$67.00
|
|
|
Service Code
|
CPT 88740
|
| Hospital Charge Code |
3006906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
SpCO
|
Facility
OP
|
$67.00
|
|
|
Service Code
|
CPT 88740
|
| Hospital Charge Code |
3006906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$268.00 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.55
|
| Rate for Payer: Anthem Medicaid |
$5.50
|
| Rate for Payer: Anthem Medicare Advantage |
$9.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.37
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.50
|
| Rate for Payer: Dean Health Medicaid |
$5.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.37
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.37
|
| Rate for Payer: Managed Health Services Medicaid |
$5.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$14.06
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.50
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$43.55
|
| Rate for Payer: Quartz Medicare Advantage |
$9.37
|
| Rate for Payer: The Alliance Commercial |
$268.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.37
|
| Rate for Payer: United Healthcare PPO |
$50.25
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: Wellcare Medicare |
$9.37
|
| Rate for Payer: WMAP Medicaid |
$5.50
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Special bed
|
Facility
OP
|
$139.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989710
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$66.72 |
| Max. Negotiated Rate |
$469.69 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.72
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$104.25
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Special bed
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989710
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Special Care Observation Per Hour
|
Facility
IP
|
$110.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040437
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Special Care Observation Per Hour
|
Facility
OP
|
$110.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040437
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$6,992.00 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Aetna Managed Medicare |
$30.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,992.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,030.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,729.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.56
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.50
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$71.50
|
| Rate for Payer: Quartz Medicare Advantage |
$66.00
|
| Rate for Payer: The Alliance Commercial |
$152.84
|
| Rate for Payer: United Healthcare PPO |
$2,598.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Special Dosimetry
|
Facility
IP
|
$745.00
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
3040385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$365.05 |
| Max. Negotiated Rate |
$685.40 |
| Rate for Payer: Aetna Commercial |
$670.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$394.85
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$685.40
|
| Rate for Payer: Health EOS Commercial |
$663.05
|
| Rate for Payer: HFN Commercial |
$685.40
|
| Rate for Payer: Multiplan Commercial |
$596.00
|
| Rate for Payer: NAPHCARE Commercial |
$447.00
|
| Rate for Payer: Preferred Network Access Commercial |
$685.40
|
| Rate for Payer: Quartz Beloit One Network |
$365.05
|
| Rate for Payer: Quartz Commercial |
$447.00
|
| Rate for Payer: WEA Trust Commercial |
$409.75
|
| Rate for Payer: WPS Commercial |
$551.82
|
|
|
Special Dosimetry
|
Facility
OP
|
$745.00
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
3040385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$134.11 |
| Max. Negotiated Rate |
$685.40 |
| Rate for Payer: Aetna Commercial |
$670.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$640.70
|
| Rate for Payer: Aetna Managed Medicare |
$134.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$502.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$402.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$382.21
|
| Rate for Payer: Anthem Medicare Advantage |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$394.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$134.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$134.11
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$685.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$134.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$134.11
|
| Rate for Payer: Health EOS Commercial |
$663.05
|
| Rate for Payer: HFN Commercial |
$685.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$134.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$134.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$134.11
|
| Rate for Payer: Multiplan Commercial |
$596.00
|
| Rate for Payer: NAPHCARE Commercial |
$201.16
|
| Rate for Payer: Preferred Network Access Commercial |
$685.40
|
| Rate for Payer: Quartz Beloit One Network |
$365.05
|
| Rate for Payer: Quartz Commercial |
$484.25
|
| Rate for Payer: Quartz Medicare Advantage |
$134.11
|
| Rate for Payer: The Alliance Commercial |
$136.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$134.11
|
| Rate for Payer: United Healthcare PPO |
$558.75
|
| Rate for Payer: WEA Trust Commercial |
$409.75
|
| Rate for Payer: Wellcare Medicare |
$134.11
|
| Rate for Payer: WPS Commercial |
$551.82
|
|
|
Special Dosimetry 7733126
|
Professional
|
$291.00
|
|
|
Service Code
|
CPT 77331 26
|
| Hospital Charge Code |
5258633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.39 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Aetna Commercial |
$276.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$44.39
|
| Rate for Payer: Anthem Medicare Advantage |
$44.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$44.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$44.39
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$276.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.39
|
| Rate for Payer: Health EOS Commercial |
$264.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$157.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$157.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$44.39
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: Preferred Network Access Commercial |
$276.45
|
| Rate for Payer: Quartz Beloit One Network |
$128.04
|
| Rate for Payer: Quartz Commercial |
$165.87
|
| Rate for Payer: Quartz Medicare Advantage |
$44.39
|
| Rate for Payer: The Alliance Commercial |
$168.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.39
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$221.95
|
|
|
Special Ophthalmolgical Services: Biometry With IOL Calculation
|
Professional
|
$123.00
|
|
|
Service Code
|
CPT 92136
|
| Hospital Charge Code |
1188927
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.55 |
| Max. Negotiated Rate |
$186.74 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$45.55
|
| Rate for Payer: Anthem Medicare Advantage |
$45.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.55
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.55
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$186.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.55
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: Quartz Medicare Advantage |
$45.55
|
| Rate for Payer: The Alliance Commercial |
$113.88
|
| Rate for Payer: United Healthcare Medicaid |
$74.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.55
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$182.20
|
|
|
Special Ophthalmolgical Services: Corneal Topography With Interpretation
|
Professional
|
$58.00
|
|
|
Service Code
|
CPT 92025
|
| Hospital Charge Code |
1188931
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$139.72 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Aetna Managed Medicare |
$34.93
|
| Rate for Payer: Anthem Medicare Advantage |
$34.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$34.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$34.93
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.93
|
| Rate for Payer: Health EOS Commercial |
$52.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$125.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$34.93
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: Preferred Network Access Commercial |
$55.10
|
| Rate for Payer: Quartz Beloit One Network |
$25.52
|
| Rate for Payer: Quartz Commercial |
$33.06
|
| Rate for Payer: Quartz Medicare Advantage |
$34.93
|
| Rate for Payer: The Alliance Commercial |
$87.32
|
| Rate for Payer: United Healthcare Medicaid |
$23.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$34.93
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$139.72
|
|
|
Special Ophthalmolgical Services: Fluorescein Angiography With Interpretation
|
Professional
|
$401.00
|
|
|
Service Code
|
CPT 92235
|
| Hospital Charge Code |
1188929
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.45 |
| Max. Negotiated Rate |
$530.04 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Aetna Managed Medicare |
$132.51
|
| Rate for Payer: Anthem Medicare Advantage |
$132.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$132.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$132.51
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$380.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$200.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.51
|
| Rate for Payer: Health EOS Commercial |
$364.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$400.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$132.51
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: Preferred Network Access Commercial |
$380.95
|
| Rate for Payer: Quartz Beloit One Network |
$176.44
|
| Rate for Payer: Quartz Commercial |
$228.57
|
| Rate for Payer: Quartz Medicare Advantage |
$132.51
|
| Rate for Payer: The Alliance Commercial |
$331.28
|
| Rate for Payer: United Healthcare Medicaid |
$108.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.51
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$530.04
|
|
|
Special Ophthalmolgical Services: Fundus Photography With Interpretation
|
Professional
|
$100.00
|
|
|
Service Code
|
CPT 92250
|
| Hospital Charge Code |
1188928
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$143.92 |
| Rate for Payer: Aetna Commercial |
$95.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$35.98
|
| Rate for Payer: Anthem Medicare Advantage |
$35.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.98
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.98
|
| Rate for Payer: Health EOS Commercial |
$91.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$133.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.98
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: Preferred Network Access Commercial |
$95.00
|
| Rate for Payer: Quartz Beloit One Network |
$44.00
|
| Rate for Payer: Quartz Commercial |
$57.00
|
| Rate for Payer: Quartz Medicare Advantage |
$35.98
|
| Rate for Payer: The Alliance Commercial |
$89.95
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.98
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$143.92
|
|
