|
Soft Interface below Knee Se L2820
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS L2820
|
| Hospital Charge Code |
4718607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$128.42 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$157.25
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
Soft Interface below Knee Se L2820
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS L2820
|
| Hospital Charge Code |
4718607
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$415.13 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Aetna Managed Medicare |
$73.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.66
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.56
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: NAPHCARE Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$170.35
|
| Rate for Payer: Quartz Medicare Advantage |
$157.25
|
| Rate for Payer: The Alliance Commercial |
$415.13
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
SOFT TISSUE PROCEDURES WITH CC
|
Facility
|
IP
|
$48,324.64
|
|
|
Service Code
|
MSDRG 501
|
| Min. Negotiated Rate |
$13,894.07 |
| Max. Negotiated Rate |
$48,324.64 |
| Rate for Payer: Aetna Managed Medicare |
$13,894.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,142.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,235.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,775.77
|
| Rate for Payer: Anthem Medicare Advantage |
$13,894.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,894.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,894.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,894.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,833.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,894.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,200.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,894.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,894.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,894.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,894.07
|
| Rate for Payer: NAPHCARE Commercial |
$20,841.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13,894.07
|
| Rate for Payer: The Alliance Commercial |
$48,324.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,894.07
|
| Rate for Payer: United Healthcare PPO |
$27,403.65
|
| Rate for Payer: Wellcare Medicare |
$13,894.07
|
|
|
SOFT TISSUE PROCEDURES WITH MCC
|
Facility
|
IP
|
$89,994.32
|
|
|
Service Code
|
MSDRG 500
|
| Min. Negotiated Rate |
$24,743.45 |
| Max. Negotiated Rate |
$89,994.32 |
| Rate for Payer: Aetna Managed Medicare |
$24,743.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52,928.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50,285.89
|
| Rate for Payer: Anthem Medicare Advantage |
$24,743.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24,743.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24,743.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24,743.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55,821.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24,743.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65,763.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24,743.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24,743.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24,743.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24,743.45
|
| Rate for Payer: NAPHCARE Commercial |
$37,115.18
|
| Rate for Payer: Quartz Medicare Advantage |
$24,743.45
|
| Rate for Payer: The Alliance Commercial |
$89,994.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24,743.45
|
| Rate for Payer: United Healthcare PPO |
$51,198.11
|
| Rate for Payer: Wellcare Medicare |
$24,743.45
|
|
|
SOFT TISSUE PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$38,564.24
|
|
|
Service Code
|
MSDRG 502
|
| Min. Negotiated Rate |
$10,813.94 |
| Max. Negotiated Rate |
$38,564.24 |
| Rate for Payer: Aetna Managed Medicare |
$10,813.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,366.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,509.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,385.17
|
| Rate for Payer: Anthem Medicare Advantage |
$10,813.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,813.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,813.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,813.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,739.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,813.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,041.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,813.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,813.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,813.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,813.94
|
| Rate for Payer: NAPHCARE Commercial |
$16,220.91
|
| Rate for Payer: Quartz Medicare Advantage |
$10,813.94
|
| Rate for Payer: The Alliance Commercial |
$38,564.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,813.94
|
| Rate for Payer: United Healthcare PPO |
$21,830.40
|
| Rate for Payer: Wellcare Medicare |
$10,813.94
|
|
|
SOL.0.45% S.C.WATER 1000ML
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2962801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
SOL.0.45% S.C.WATER 1000ML
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2962801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
SOL.0.45%S.C.WATER 500 7985-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963806
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.0.45%S.C.WATER 500 7985-03
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2963806
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$17.68
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.0.9%S.C.IRRIG 3000 NDC 0409-7972-08
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2963791
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SOL.0.9%S.C.IRRIG 3000 NDC 0409-7972-08
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2963791
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
SOL.10%D/W 1000 BAG
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2963854
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
SOL.10%D/W 1000 BAG
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2963854
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
SOL.250 5%D/WATER 152202
|
Facility
|
OP
|
$106.00
|
|
| Hospital Charge Code |
3000487
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$30.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.69
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.68
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$66.14
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$71.66
|
| Rate for Payer: Quartz Medicare Advantage |
$66.14
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
SOL.250 5%D/WATER 152202
|
Facility
|
IP
|
$106.00
|
|
| Hospital Charge Code |
3000487
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$54.02 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$66.14
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
SOL 5%D/45%SOD CHL 500 7926-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963808
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL 5%D/45%SOD CHL 500 7926-03
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2963808
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$17.68
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.5%DEX/.225%S.C.500 7924-03
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2963740
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$17.68
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.5%DEX/.225%S.C.500 7924-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963740
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.5%DEX/2%S.C.1000
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2963878
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
SOL.5%DEX/2%S.C.1000
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2963878
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
SOL.5%DEX/45 SODCHL L
|
Facility
|
IP
|
$158.00
|
|
| Hospital Charge Code |
2963885
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
SOL.5%DEX/45 SODCHL L
|
Facility
|
OP
|
$158.00
|
|
| Hospital Charge Code |
2963885
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$46.01 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.24
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
SOL.5%DEX/9%S.C.500 7941-03
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2963807
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
SOL.5%DEX/9%S.C.500 7941-03
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2963807
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$17.68
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
