|
SPONGE NEURO 1/2 X 1/2 XRAY DETEC NEUROSPNG05"
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SPONGE NEURO 1/2 X 1/2 XRAY DETEC NEUROSPNG05"
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SPONGE NEURO 1/2 X 3 XRAY DETEC NEUROSPNG09"
|
Facility
|
IP
|
$185.00
|
|
| Hospital Charge Code |
2963126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.28 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$115.44
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
SPONGE NEURO 1/2 X 3 XRAY DETEC NEUROSPNG09"
|
Facility
|
OP
|
$185.00
|
|
| Hospital Charge Code |
2963126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Aetna Managed Medicare |
$53.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.67
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.30
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: NAPHCARE Commercial |
$115.44
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$125.06
|
| Rate for Payer: Quartz Medicare Advantage |
$115.44
|
| Rate for Payer: The Alliance Commercial |
$96.20
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
SPONGE NEURO 1 X 3 XRAY DETEC NEUROSPNG14"
|
Facility
|
OP
|
$178.00
|
|
| Hospital Charge Code |
2963136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.83 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$51.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.60
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$111.07
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$111.07
|
| Rate for Payer: The Alliance Commercial |
$92.56
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
SPONGE NEURO 1 X 3 XRAY DETEC NEUROSPNG14"
|
Facility
|
IP
|
$178.00
|
|
| Hospital Charge Code |
2963136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
SPONGE PEANUT w/SPONGE HOLDER 7103
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
2963252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
SPONGE PEANUT w/SPONGE HOLDER 7103
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
2963252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
SPONGE RAYTEX 4 X 4 16 PLY 7317
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
2962819
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$20.59
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
SPONGE RAYTEX 4 X 4 16 PLY 7317
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2962819
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Aetna Managed Medicare |
$9.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.21
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.74
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.59
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$22.31
|
| Rate for Payer: Quartz Medicare Advantage |
$20.59
|
| Rate for Payer: The Alliance Commercial |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
SPONGE STICKS SKIN PREP PAINT WITH PVP 41550
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
2962811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
SPONGE STICKS SKIN PREP PAINT WITH PVP 41550
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
2962811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
SPONGE TONSIL SINGLE STRUNG 7201
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2963184
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
SPONGE TONSIL SINGLE STRUNG 7201
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2963184
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
SPONTANEOUS NYSTAGMUS TEST 9254126
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
CPT 92541
|
| Hospital Charge Code |
3015332
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.74 |
| Max. Negotiated Rate |
$176.85 |
| Rate for Payer: Aetna Commercial |
$176.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.10
|
| Rate for Payer: Aetna Managed Medicare |
$24.74
|
| Rate for Payer: Anthem Medicare Advantage |
$24.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.74
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Cigna Commercial |
$176.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.74
|
| Rate for Payer: Health EOS Commercial |
$169.41
|
| Rate for Payer: HFN Commercial |
$176.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.74
|
| Rate for Payer: Multiplan Commercial |
$148.93
|
| Rate for Payer: NAPHCARE Commercial |
$37.11
|
| Rate for Payer: Preferred Network Access Commercial |
$176.85
|
| Rate for Payer: Quartz Beloit One Network |
$81.91
|
| Rate for Payer: Quartz Commercial |
$106.11
|
| Rate for Payer: Quartz Medicare Advantage |
$24.74
|
| Rate for Payer: The Alliance Commercial |
$61.85
|
| Rate for Payer: United Healthcare Medicaid |
$29.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.74
|
| Rate for Payer: WEA Trust Commercial |
$102.39
|
| Rate for Payer: WPS Commercial |
$98.97
|
|
|
SPOT CURVED SP-01
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2970793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
SPOT CURVED SP-01
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2970793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
SPOT JO-JU #SP-07
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2970673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPOT JO-JU #SP-07
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2970673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$166.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.88
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
SPOT KATINA LARGE #SP-05L
|
Facility
|
IP
|
$367.00
|
|
| Hospital Charge Code |
2971003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
SPOT KATINA LARGE #SP-05L
|
Facility
|
OP
|
$367.00
|
|
| Hospital Charge Code |
2971003
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
SPOT KATINA SMALL #SP-05S
|
Facility
|
IP
|
$342.00
|
|
| Hospital Charge Code |
2970971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.28 |
| Max. Negotiated Rate |
$327.23 |
| Rate for Payer: Aetna Commercial |
$320.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$305.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.51
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$327.23
|
| Rate for Payer: Health EOS Commercial |
$316.56
|
| Rate for Payer: HFN Commercial |
$327.23
|
| Rate for Payer: Multiplan Commercial |
$284.54
|
| Rate for Payer: Preferred Network Access Commercial |
$327.23
|
| Rate for Payer: Quartz Beloit One Network |
$174.28
|
| Rate for Payer: Quartz Commercial |
$213.41
|
| Rate for Payer: WEA Trust Commercial |
$195.62
|
| Rate for Payer: WPS Commercial |
$263.44
|
|
|
SPOT KATINA SMALL #SP-05S
|
Facility
|
OP
|
$342.00
|
|
| Hospital Charge Code |
2970971
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.59 |
| Max. Negotiated Rate |
$327.23 |
| Rate for Payer: Aetna Commercial |
$320.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$305.88
|
| Rate for Payer: Aetna Managed Medicare |
$99.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$231.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$170.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.51
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Cigna Commercial |
$327.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.04
|
| Rate for Payer: Health EOS Commercial |
$316.56
|
| Rate for Payer: HFN Commercial |
$327.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$266.76
|
| Rate for Payer: Multiplan Commercial |
$284.54
|
| Rate for Payer: NAPHCARE Commercial |
$213.41
|
| Rate for Payer: Preferred Network Access Commercial |
$327.23
|
| Rate for Payer: Quartz Beloit One Network |
$174.28
|
| Rate for Payer: Quartz Commercial |
$231.19
|
| Rate for Payer: Quartz Medicare Advantage |
$213.41
|
| Rate for Payer: The Alliance Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$195.62
|
| Rate for Payer: WPS Commercial |
$263.44
|
|
|
SPOT OVAL SP-04
|
Facility
|
IP
|
$269.00
|
|
| Hospital Charge Code |
2970856
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$137.08 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$167.86
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
SPOT OVAL SP-04
|
Facility
|
OP
|
$269.00
|
|
| Hospital Charge Code |
2970856
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.33 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$78.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.56
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.82
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$167.86
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$181.84
|
| Rate for Payer: Quartz Medicare Advantage |
$167.86
|
| Rate for Payer: The Alliance Commercial |
$139.88
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
