|
SLING STRAP ARM w/PAD SMALL 8006-02
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2964022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
SLING STRAP ARM w/PAD SMALL 8006-02
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2964022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
SLING XL 280-450 LB #50313
|
Facility
|
IP
|
$3,038.00
|
|
| Hospital Charge Code |
2970186
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,488.62 |
| Max. Negotiated Rate |
$2,794.96 |
| Rate for Payer: Aetna Commercial |
$2,734.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,612.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,610.14
|
| Rate for Payer: Cash Price |
$911.40
|
| Rate for Payer: Cigna Commercial |
$2,794.96
|
| Rate for Payer: Health EOS Commercial |
$2,703.82
|
| Rate for Payer: HFN Commercial |
$2,794.96
|
| Rate for Payer: Multiplan Commercial |
$2,430.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,822.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,794.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,488.62
|
| Rate for Payer: Quartz Commercial |
$1,822.80
|
| Rate for Payer: WEA Trust Commercial |
$1,670.90
|
| Rate for Payer: WPS Commercial |
$2,250.25
|
|
|
SLING XL 280-450 LB #50313
|
Facility
|
OP
|
$3,038.00
|
|
| Hospital Charge Code |
2970186
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$850.64 |
| Max. Negotiated Rate |
$12,152.00 |
| Rate for Payer: Aetna Commercial |
$2,734.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,612.68
|
| Rate for Payer: Aetna Managed Medicare |
$850.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,974.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,519.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,458.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,610.14
|
| Rate for Payer: Cash Price |
$911.40
|
| Rate for Payer: Cigna Commercial |
$2,794.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,700.06
|
| Rate for Payer: Health EOS Commercial |
$2,703.82
|
| Rate for Payer: HFN Commercial |
$2,794.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,278.50
|
| Rate for Payer: Multiplan Commercial |
$2,430.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,822.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,794.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,488.62
|
| Rate for Payer: Quartz Commercial |
$1,974.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,822.80
|
| Rate for Payer: The Alliance Commercial |
$12,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,670.90
|
| Rate for Payer: WPS Commercial |
$2,250.25
|
|
|
SLIT KNIFE SINGLE BEVEL 2.4MM 8065992445
|
Facility
|
OP
|
$471.00
|
|
| Hospital Charge Code |
5415573
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.88 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Aetna Managed Medicare |
$131.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$306.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$226.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.57
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.25
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$306.15
|
| Rate for Payer: Quartz Medicare Advantage |
$282.60
|
| Rate for Payer: The Alliance Commercial |
$1,884.00
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
SLIT KNIFE SINGLE BEVEL 2.4MM 8065992445
|
Facility
|
IP
|
$471.00
|
|
| Hospital Charge Code |
5415573
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$230.79 |
| Max. Negotiated Rate |
$433.32 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.63
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$282.60
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$282.60
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
SLITTING OF PREPUCE 54001
|
Professional
|
Both
|
$476.00
|
|
|
Service Code
|
CPT 54001
|
| Hospital Charge Code |
3015017
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$90.38 |
| Max. Negotiated Rate |
$468.71 |
| Rate for Payer: Aetna Commercial |
$452.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$409.36
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$452.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.60
|
| Rate for Payer: Health EOS Commercial |
$433.16
|
| Rate for Payer: HFN Commercial |
$452.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$468.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$468.71
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: Preferred Network Access Commercial |
$452.20
|
| Rate for Payer: Quartz Beloit One Network |
$209.44
|
| Rate for Payer: Quartz Commercial |
$271.32
|
| Rate for Payer: The Alliance Commercial |
$238.00
|
| Rate for Payer: United Healthcare Medicaid |
$90.38
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
SLOTTED PLATE HOFFMAN LIMB 4934-1-060
|
Facility
|
OP
|
$1,583.00
|
|
| Hospital Charge Code |
6001646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$443.24 |
| Max. Negotiated Rate |
$6,332.00 |
| Rate for Payer: Aetna Commercial |
$1,424.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,361.38
|
| Rate for Payer: Aetna Managed Medicare |
$443.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,028.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$791.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$759.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$838.99
|
| Rate for Payer: Cash Price |
$474.90
|
| Rate for Payer: Cigna Commercial |
$1,456.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$885.85
|
| Rate for Payer: Health EOS Commercial |
$1,408.87
|
| Rate for Payer: HFN Commercial |
$1,456.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,187.25
|
| Rate for Payer: Multiplan Commercial |
$1,266.40
|
| Rate for Payer: NAPHCARE Commercial |
$949.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,456.36
|
| Rate for Payer: Quartz Beloit One Network |
$775.67
|
| Rate for Payer: Quartz Commercial |
$1,028.95
|
| Rate for Payer: Quartz Medicare Advantage |
$949.80
|
| Rate for Payer: The Alliance Commercial |
$6,332.00
|
| Rate for Payer: WEA Trust Commercial |
$870.65
|
| Rate for Payer: WPS Commercial |
$1,172.53
|
|
|
SLOTTED PLATE HOFFMAN LIMB 4934-1-060
|
Facility
|
IP
|
$1,583.00
|
|
| Hospital Charge Code |
6001646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$775.67 |
| Max. Negotiated Rate |
$1,456.36 |
| Rate for Payer: Aetna Commercial |
$1,424.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,361.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$838.99
|
| Rate for Payer: Cash Price |
$474.90
|
| Rate for Payer: Cigna Commercial |
$1,456.36
|
| Rate for Payer: Health EOS Commercial |
$1,408.87
|
| Rate for Payer: HFN Commercial |
$1,456.36
|
| Rate for Payer: Multiplan Commercial |
$1,266.40
|
| Rate for Payer: NAPHCARE Commercial |
$949.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,456.36
|
| Rate for Payer: Quartz Beloit One Network |
$775.67
|
| Rate for Payer: Quartz Commercial |
$949.80
|
| Rate for Payer: WEA Trust Commercial |
$870.65
|
| Rate for Payer: WPS Commercial |
$1,172.53
|
|
|
SLP Cognitive Function Intervention Chrg
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 97129 GN
|
| Hospital Charge Code |
5344656
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: United Healthcare PPO |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
SLP Cognitive Function Intervention Chrg
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 97129 GN
|
| Hospital Charge Code |
5344656
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Sm-153 Lexidronam(per 50 mCi)
|
Facility
|
OP
|
$14,944.00
|
|
|
Service Code
|
HCPCS A9604
|
| Hospital Charge Code |
1486846
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$7,173.12 |
| Max. Negotiated Rate |
$69,039.41 |
| Rate for Payer: Aetna Commercial |
$13,449.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,851.84
|
| Rate for Payer: Aetna Managed Medicare |
$17,259.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,713.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,472.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,173.12
|
| Rate for Payer: Anthem Medicare Advantage |
$17,259.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,920.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,259.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,259.85
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cigna Commercial |
$13,748.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,259.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,362.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,259.85
|
| Rate for Payer: Health EOS Commercial |
$13,300.16
|
| Rate for Payer: HFN Commercial |
$13,748.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64,206.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,259.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,259.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,259.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,259.85
|
| Rate for Payer: Multiplan Commercial |
$11,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$25,889.78
|
| Rate for Payer: Preferred Network Access Commercial |
$13,748.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,322.56
|
| Rate for Payer: Quartz Commercial |
$9,713.60
|
| Rate for Payer: Quartz Medicare Advantage |
$17,259.85
|
| Rate for Payer: The Alliance Commercial |
$69,039.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,259.85
|
| Rate for Payer: WEA Trust Commercial |
$8,219.20
|
| Rate for Payer: Wellcare Medicare |
$17,259.85
|
| Rate for Payer: WPS Commercial |
$11,069.02
|
|
|
Sm-153 Lexidronam(per 50 mCi)
|
Professional
|
Both
|
$14,944.00
|
|
|
Service Code
|
HCPCS A9604
|
| Hospital Charge Code |
1486846
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$6,575.36 |
| Max. Negotiated Rate |
$28,527.61 |
| Rate for Payer: Aetna Commercial |
$14,196.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,851.84
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cigna Commercial |
$14,196.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,472.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,966.40
|
| Rate for Payer: Health EOS Commercial |
$13,599.04
|
| Rate for Payer: HFN Commercial |
$14,196.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,527.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28,527.61
|
| Rate for Payer: Multiplan Commercial |
$11,955.20
|
| Rate for Payer: Preferred Network Access Commercial |
$14,196.80
|
| Rate for Payer: Quartz Beloit One Network |
$6,575.36
|
| Rate for Payer: Quartz Commercial |
$8,518.08
|
| Rate for Payer: The Alliance Commercial |
$7,472.00
|
| Rate for Payer: WEA Trust Commercial |
$8,219.20
|
| Rate for Payer: WPS Commercial |
$11,069.02
|
|
|
Sm-153 Lexidronam(per 50 mCi)
|
Facility
|
IP
|
$14,944.00
|
|
|
Service Code
|
HCPCS A9604
|
| Hospital Charge Code |
1486846
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$7,322.56 |
| Max. Negotiated Rate |
$13,748.48 |
| Rate for Payer: Aetna Commercial |
$13,449.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,851.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,920.32
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cigna Commercial |
$13,748.48
|
| Rate for Payer: Health EOS Commercial |
$13,300.16
|
| Rate for Payer: HFN Commercial |
$13,748.48
|
| Rate for Payer: Multiplan Commercial |
$11,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,966.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,748.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,322.56
|
| Rate for Payer: Quartz Commercial |
$8,966.40
|
| Rate for Payer: WEA Trust Commercial |
$8,219.20
|
| Rate for Payer: WPS Commercial |
$11,069.02
|
|
|
SMA Carrier Screen
|
Facility
|
IP
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$662.97 |
| Max. Negotiated Rate |
$1,244.76 |
| Rate for Payer: Aetna Commercial |
$1,217.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,163.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$717.09
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,244.76
|
| Rate for Payer: Health EOS Commercial |
$1,204.17
|
| Rate for Payer: HFN Commercial |
$1,244.76
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$811.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,244.76
|
| Rate for Payer: Quartz Beloit One Network |
$662.97
|
| Rate for Payer: Quartz Commercial |
$811.80
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: WPS Commercial |
$1,002.17
|
|
|
SMA Carrier Screen
|
Facility
|
OP
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$1,244.76 |
| Rate for Payer: Aetna Commercial |
$1,217.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,163.58
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$513.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.42
|
| Rate for Payer: Anthem Medicaid |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$717.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,244.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$757.14
|
| Rate for Payer: Dean Health Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,204.17
|
| Rate for Payer: HFN Commercial |
$1,244.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$509.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Managed Health Services Medicaid |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$205.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,244.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$137.00
|
| Rate for Payer: Quartz Beloit One Network |
$662.97
|
| Rate for Payer: Quartz Commercial |
$879.45
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$548.00
|
| Rate for Payer: United Healthcare Medicaid |
$137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: United Healthcare PPO |
$1,014.75
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: Wellcare Medicare |
$137.00
|
| Rate for Payer: WMAP Medicaid |
$137.00
|
| Rate for Payer: WPS Commercial |
$1,002.17
|
|
|
SMA Carrier Screen
|
Professional
|
Both
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$483.61 |
| Max. Negotiated Rate |
$1,285.35 |
| Rate for Payer: Aetna Commercial |
$1,285.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,163.58
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,285.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$676.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$811.80
|
| Rate for Payer: Health EOS Commercial |
$1,231.23
|
| Rate for Payer: HFN Commercial |
$1,285.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.61
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.35
|
| Rate for Payer: Quartz Beloit One Network |
$595.32
|
| Rate for Payer: Quartz Commercial |
$771.21
|
| Rate for Payer: The Alliance Commercial |
$676.50
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: WPS Commercial |
$1,002.17
|
|
|
SMA Diagnostic Test
|
Professional
|
Both
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$483.61 |
| Max. Negotiated Rate |
$1,105.80 |
| Rate for Payer: Aetna Commercial |
$1,105.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,105.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$582.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$698.40
|
| Rate for Payer: Health EOS Commercial |
$1,059.24
|
| Rate for Payer: HFN Commercial |
$1,105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.61
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,105.80
|
| Rate for Payer: Quartz Beloit One Network |
$512.16
|
| Rate for Payer: Quartz Commercial |
$663.48
|
| Rate for Payer: The Alliance Commercial |
$582.00
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
SMA Diagnostic Test
|
Facility
|
IP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$570.36 |
| Max. Negotiated Rate |
$1,070.88 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$698.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$698.40
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
SMA Diagnostic Test
|
Facility
|
OP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$1,070.88 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$513.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.42
|
| Rate for Payer: Anthem Medicaid |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$651.37
|
| Rate for Payer: Dean Health Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$509.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Managed Health Services Medicaid |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$205.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$137.00
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$756.60
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$548.00
|
| Rate for Payer: United Healthcare Medicaid |
$137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: United Healthcare PPO |
$873.00
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: Wellcare Medicare |
$137.00
|
| Rate for Payer: WMAP Medicaid |
$137.00
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
Small black foam
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$179.76 |
| Max. Negotiated Rate |
$2,568.00 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.12
|
| Rate for Payer: Aetna Managed Medicare |
$179.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$417.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$321.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$308.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$359.26
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$481.50
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$417.30
|
| Rate for Payer: Quartz Medicare Advantage |
$385.20
|
| Rate for Payer: The Alliance Commercial |
$2,568.00
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
|
Small black foam
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$314.58 |
| Max. Negotiated Rate |
$590.64 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$385.20
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
|
SMALL BOWEL RESECTION
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
SMALL BOWEL RESECTION
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$119.38 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.20
|
| Rate for Payer: Health EOS Commercial |
$74.62
|
| Rate for Payer: HFN Commercial |
$77.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$119.38
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: Preferred Network Access Commercial |
$77.90
|
| Rate for Payer: Quartz Beloit One Network |
$36.08
|
| Rate for Payer: Quartz Commercial |
$46.74
|
| Rate for Payer: The Alliance Commercial |
$41.00
|
| Rate for Payer: United Healthcare Medicaid |
$38.73
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
