|
Splint wrist or ankle S8451
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS S8451
|
| Hospital Charge Code |
4506587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Splint wrist or ankle S8451
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS S8451
|
| Hospital Charge Code |
4506587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Splint wrist or ankle S8451
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS S8451
|
| Hospital Charge Code |
4506587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Split Flat Caliper Stirr & P L2230
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS L2230
|
| Hospital Charge Code |
4718606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Split Flat Caliper Stirr & P L2230
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS L2230
|
| Hospital Charge Code |
4718606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.25
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Split Flat Caliper Stirr & P L2230
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
HCPCS L2230
|
| Hospital Charge Code |
4718606
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$98.12 |
| Max. Negotiated Rate |
$338.95 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.80
|
| Rate for Payer: Health EOS Commercial |
$202.93
|
| Rate for Payer: HFN Commercial |
$211.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$338.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$338.95
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: Preferred Network Access Commercial |
$211.85
|
| Rate for Payer: Quartz Beloit One Network |
$98.12
|
| Rate for Payer: Quartz Commercial |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$111.50
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$13,191.23
|
|
|
Service Code
|
CPT 15120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,546.03 |
| Max. Negotiated Rate |
$13,191.23 |
| Rate for Payer: Aetna Managed Medicare |
$3,546.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,546.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,546.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,546.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,191.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,546.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,546.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,546.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,546.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,319.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3,546.03
|
| Rate for Payer: The Alliance Commercial |
$6,028.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,546.03
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,546.03
|
|
|
S. pneumoniae Antigen
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$80.96 |
| Rate for Payer: Aetna Commercial |
$79.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.64
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$80.96
|
| Rate for Payer: Health EOS Commercial |
$78.32
|
| Rate for Payer: HFN Commercial |
$80.96
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$80.96
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$52.80
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
S. pneumoniae Antigen
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$83.60 |
| Rate for Payer: Aetna Commercial |
$83.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$83.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.80
|
| Rate for Payer: Health EOS Commercial |
$80.08
|
| Rate for Payer: HFN Commercial |
$83.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.74
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: Preferred Network Access Commercial |
$83.60
|
| Rate for Payer: Quartz Beloit One Network |
$38.72
|
| Rate for Payer: Quartz Commercial |
$50.16
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
S. pneumoniae Antigen
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$80.96 |
| Rate for Payer: Aetna Commercial |
$79.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Aetna Managed Medicare |
$11.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.16
|
| Rate for Payer: Anthem Medicaid |
$11.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.54
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$80.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.24
|
| Rate for Payer: Dean Health Medicaid |
$11.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.54
|
| Rate for Payer: Health EOS Commercial |
$78.32
|
| Rate for Payer: HFN Commercial |
$80.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.54
|
| Rate for Payer: Managed Health Services Medicaid |
$12.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.54
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: NAPHCARE Commercial |
$17.31
|
| Rate for Payer: Preferred Network Access Commercial |
$80.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.92
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$57.20
|
| Rate for Payer: Quartz Medicare Advantage |
$11.54
|
| Rate for Payer: The Alliance Commercial |
$46.16
|
| Rate for Payer: United Healthcare Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.54
|
| Rate for Payer: United Healthcare PPO |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: Wellcare Medicare |
$11.54
|
| Rate for Payer: WMAP Medicaid |
$11.92
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
S Pneumoniae Antigen
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Aetna Managed Medicare |
$11.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.16
|
| Rate for Payer: Anthem Medicaid |
$11.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.54
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.14
|
| Rate for Payer: Dean Health Medicaid |
$11.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.54
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.54
|
| Rate for Payer: Managed Health Services Medicaid |
$12.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.54
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.31
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.92
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$165.10
|
| Rate for Payer: Quartz Medicare Advantage |
$11.54
|
| Rate for Payer: The Alliance Commercial |
$46.16
|
| Rate for Payer: United Healthcare Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.54
|
| Rate for Payer: United Healthcare PPO |
$190.50
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: Wellcare Medicare |
$11.54
|
| Rate for Payer: WMAP Medicaid |
$11.92
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
S Pneumoniae Antigen
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.46 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$152.40
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
S Pneumoniae Antigen
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.74 |
| Max. Negotiated Rate |
$241.30 |
| Rate for Payer: Aetna Commercial |
$241.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$241.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.40
|
| Rate for Payer: Health EOS Commercial |
$231.14
|
| Rate for Payer: HFN Commercial |
$241.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.74
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: Preferred Network Access Commercial |
$241.30
|
| Rate for Payer: Quartz Beloit One Network |
$111.76
|
| Rate for Payer: Quartz Commercial |
$144.78
|
| Rate for Payer: The Alliance Commercial |
$127.00
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
SPONGE 18 X 18 LAP MDS231318LF
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
2963614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
SPONGE 18 X 18 LAP MDS231318LF
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
2963614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
SPONGE EYE SPEAR 1 1/4 7301
|
Facility
|
OP
|
$1,838.00
|
|
| Hospital Charge Code |
2969029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.64 |
| Max. Negotiated Rate |
$7,352.00 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Aetna Managed Medicare |
$514.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,194.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$882.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,028.54
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,378.50
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,194.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,102.80
|
| Rate for Payer: The Alliance Commercial |
$7,352.00
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
SPONGE EYE SPEAR 1 1/4 7301
|
Facility
|
IP
|
$1,838.00
|
|
| Hospital Charge Code |
2969029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$900.62 |
| Max. Negotiated Rate |
$1,690.96 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,102.80
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
SPONGE GAUZE BULK NON-STRL 4x4
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
2963400
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$724.00 |
| Rate for Payer: Aetna Commercial |
$162.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Aetna Managed Medicare |
$50.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$117.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$90.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.93
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$166.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.29
|
| Rate for Payer: Health EOS Commercial |
$161.09
|
| Rate for Payer: HFN Commercial |
$166.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.75
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.60
|
| Rate for Payer: Preferred Network Access Commercial |
$166.52
|
| Rate for Payer: Quartz Beloit One Network |
$88.69
|
| Rate for Payer: Quartz Commercial |
$117.65
|
| Rate for Payer: Quartz Medicare Advantage |
$108.60
|
| Rate for Payer: The Alliance Commercial |
$724.00
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
|
SPONGE GAUZE BULK NON-STRL 4x4
|
Facility
|
IP
|
$181.00
|
|
| Hospital Charge Code |
2963400
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$166.52 |
| Rate for Payer: Aetna Commercial |
$162.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.93
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$166.52
|
| Rate for Payer: Health EOS Commercial |
$161.09
|
| Rate for Payer: HFN Commercial |
$166.52
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.60
|
| Rate for Payer: Preferred Network Access Commercial |
$166.52
|
| Rate for Payer: Quartz Beloit One Network |
$88.69
|
| Rate for Payer: Quartz Commercial |
$108.60
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
|
SPONGE LAP 4x18 407
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2963536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.00
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
SPONGE LAP 4x18 407
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2963536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
SPONGE NEURO 1/2x 1-1/2 200103"
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
2963455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
SPONGE NEURO 1/2x 1-1/2 200103"
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
2963455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
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 |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
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 |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
