|
State Supplied - Varicella Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
State Supplied - Varicella Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
CPT 90716
|
| Hospital Charge Code |
3013486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$236.93 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$236.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$236.93
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$174.24
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Facility
OP
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Aetna Managed Medicare |
$126.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.94
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$339.00
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$271.20
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$293.80
|
| Rate for Payer: Quartz Medicare Advantage |
$271.20
|
| Rate for Payer: The Alliance Commercial |
$1,808.00
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Professional
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$198.88 |
| Max. Negotiated Rate |
$594.66 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.20
|
| Rate for Payer: Health EOS Commercial |
$411.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$594.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$594.66
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$429.40
|
| Rate for Payer: Quartz Beloit One Network |
$198.88
|
| Rate for Payer: Quartz Commercial |
$257.64
|
| Rate for Payer: The Alliance Commercial |
$226.00
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Static or Dynami Afo Pre Ots L4397
|
Facility
IP
|
$452.00
|
|
|
Service Code
|
HCPCS L4397
|
| Hospital Charge Code |
4598606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$415.84 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$271.20
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$271.20
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
STATLOCK DIALYSIS CATH DI0120
|
Facility
OP
|
$253.00
|
|
| Hospital Charge Code |
4520434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.84 |
| Max. Negotiated Rate |
$1,012.00 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Aetna Managed Medicare |
$70.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.58
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.75
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$151.80
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$164.45
|
| Rate for Payer: Quartz Medicare Advantage |
$151.80
|
| Rate for Payer: The Alliance Commercial |
$1,012.00
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
STATLOCK DIALYSIS CATH DI0120
|
Facility
IP
|
$253.00
|
|
| Hospital Charge Code |
4520434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.97 |
| Max. Negotiated Rate |
$232.76 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$151.80
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$151.80
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
STATLOCK FOLEY CATH DEVICE
|
Facility
OP
|
$114.00
|
|
| Hospital Charge Code |
2963318
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
STATLOCK FOLEY CATH DEVICE
|
Facility
IP
|
$114.00
|
|
| Hospital Charge Code |
2963318
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
STATLOCK ONLY PEDIATRIC SIZE
|
Facility
OP
|
$104.00
|
|
| Hospital Charge Code |
2964039
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$416.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
STATLOCK ONLY PEDIATRIC SIZE
|
Facility
IP
|
$104.00
|
|
| Hospital Charge Code |
2964039
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
STATLOCK PICC CATH SECUREMENT
|
Facility
OP
|
$146.00
|
|
| Hospital Charge Code |
2964019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: The Alliance Commercial |
$584.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
STATLOCK PICC CATH SECUREMENT
|
Facility
IP
|
$146.00
|
|
| Hospital Charge Code |
2964019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
STAXI-2 RATING SHEETS
|
Facility
IP
|
$90.00
|
|
| Hospital Charge Code |
2972415
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
STAXI-2 RATING SHEETS
|
Facility
OP
|
$90.00
|
|
| Hospital Charge Code |
2972415
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
STAXI-2 REUSABLE ITEM
|
Facility
OP
|
$70.00
|
|
| Hospital Charge Code |
2971977
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
STAXI-2 REUSABLE ITEM
|
Facility
IP
|
$70.00
|
|
| Hospital Charge Code |
2971977
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
ST Balloon Exp 10mm x 38mm
|
Facility
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ST Balloon Exp 10mm x 38mm
|
Facility
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ST Balloon Exp 10mm x 38mm
|
Professional
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ST Balloon Exp 7mm x 38mm
|
Facility
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ST Balloon Exp 7mm x 38mm
|
Professional
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ST Balloon Exp 7mm x 38mm
|
Facility
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2550982
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
STEADY STRIDER ANTERIOR AFO
|
Facility
OP
|
$470.00
|
|
| Hospital Charge Code |
2971276
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$131.60 |
| Max. Negotiated Rate |
$1,880.00 |
| Rate for Payer: Aetna Commercial |
$423.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Aetna Managed Medicare |
$131.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$305.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$225.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.10
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$432.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.01
|
| Rate for Payer: Health EOS Commercial |
$418.30
|
| Rate for Payer: HFN Commercial |
$432.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$352.50
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$432.40
|
| Rate for Payer: Quartz Beloit One Network |
$230.30
|
| Rate for Payer: Quartz Commercial |
$305.50
|
| Rate for Payer: Quartz Medicare Advantage |
$282.00
|
| Rate for Payer: The Alliance Commercial |
$1,880.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
STEADY STRIDER ANTERIOR AFO
|
Facility
IP
|
$470.00
|
|
| Hospital Charge Code |
2971276
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$230.30 |
| Max. Negotiated Rate |
$432.40 |
| Rate for Payer: Aetna Commercial |
$423.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.10
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$432.40
|
| Rate for Payer: Health EOS Commercial |
$418.30
|
| Rate for Payer: HFN Commercial |
$432.40
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$432.40
|
| Rate for Payer: Quartz Beloit One Network |
$230.30
|
| Rate for Payer: Quartz Commercial |
$282.00
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
