|
Tobramycin/Dexamethasone Ophth Ointment 3.5gm [Med]
|
Facility
IP
|
$646.00
|
|
| Hospital Charge Code |
2974991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.54 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$387.60
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
Tobramycin/Dexamethasone Ophth Ointment 3.5gm [Med]
|
Facility
OP
|
$646.00
|
|
| Hospital Charge Code |
2974991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.88 |
| Max. Negotiated Rate |
$2,584.00 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Aetna Managed Medicare |
$180.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$323.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$361.50
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$484.50
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$419.90
|
| Rate for Payer: Quartz Medicare Advantage |
$387.60
|
| Rate for Payer: The Alliance Commercial |
$2,584.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
Tobramycin/Dexamethasone Ophth Suspension 2.5ml [Med]
|
Facility
OP
|
$587.00
|
|
| Hospital Charge Code |
2974992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.36 |
| Max. Negotiated Rate |
$2,348.00 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Aetna Managed Medicare |
$164.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$381.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$293.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$281.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.49
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.25
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$381.55
|
| Rate for Payer: Quartz Medicare Advantage |
$352.20
|
| Rate for Payer: The Alliance Commercial |
$2,348.00
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
Tobramycin/Dexamethasone Ophth Suspension 2.5ml [Med]
|
Facility
IP
|
$587.00
|
|
| Hospital Charge Code |
2974992
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$287.63 |
| Max. Negotiated Rate |
$540.04 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$352.20
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
Tobramycin, Kinetics
|
Facility
IP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
979885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Tobramycin, Kinetics
|
Professional
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
979885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$63.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$70.97
|
|
|
Tobramycin, Kinetics
|
Facility
OP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
979885
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.78
|
| Rate for Payer: Anthem Medicaid |
$16.67
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Managed Health Services Medicaid |
$17.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$24.20
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.67
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: United Healthcare Medicaid |
$16.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: United Healthcare PPO |
$287.25
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: Wellcare Medicare |
$16.13
|
| Rate for Payer: WMAP Medicaid |
$16.67
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Tobramycin Level Peak
|
Facility
IP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Tobramycin Level Peak
|
Facility
OP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.78
|
| Rate for Payer: Anthem Medicaid |
$16.67
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Managed Health Services Medicaid |
$17.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$24.20
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.67
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: United Healthcare Medicaid |
$16.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: United Healthcare PPO |
$287.25
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: Wellcare Medicare |
$16.13
|
| Rate for Payer: WMAP Medicaid |
$16.67
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Tobramycin Level Peak
|
Professional
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$63.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$70.97
|
|
|
Tobramycin Level Trough
|
Facility
IP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
Tobramycin Level Trough
|
Professional
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$63.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$70.97
|
|
|
Tobramycin Level Trough
|
Facility
OP
|
$383.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
633849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.78
|
| Rate for Payer: Anthem Medicaid |
$16.67
|
| Rate for Payer: Anthem Medicare Advantage |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.13
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicaid |
$16.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.13
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.13
|
| Rate for Payer: Managed Health Services Medicaid |
$17.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.13
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$24.20
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.67
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$16.13
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: United Healthcare Medicaid |
$16.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.13
|
| Rate for Payer: United Healthcare PPO |
$287.25
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: Wellcare Medicare |
$16.13
|
| Rate for Payer: WMAP Medicaid |
$16.67
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
TOE ARTHROPLASTY
|
Facility
IP
|
$4,912.00
|
|
| Hospital Charge Code |
2960445
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,406.88 |
| Max. Negotiated Rate |
$4,519.04 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$2,947.20
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
TOE ARTHROPLASTY
|
Facility
OP
|
$4,912.00
|
|
| Hospital Charge Code |
2960445
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,375.36 |
| Max. Negotiated Rate |
$19,648.00 |
| Rate for Payer: Aetna Commercial |
$4,420.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,224.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,375.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,192.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,456.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,603.36
|
| Rate for Payer: Cash Price |
$1,473.60
|
| Rate for Payer: Cigna Commercial |
$4,519.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,748.76
|
| Rate for Payer: Health EOS Commercial |
$4,371.68
|
| Rate for Payer: HFN Commercial |
$4,519.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,684.00
|
| Rate for Payer: Multiplan Commercial |
$3,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,519.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,406.88
|
| Rate for Payer: Quartz Commercial |
$3,192.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,947.20
|
| Rate for Payer: The Alliance Commercial |
$19,648.00
|
| Rate for Payer: WEA Trust Commercial |
$2,701.60
|
| Rate for Payer: WPS Commercial |
$3,638.32
|
|
|
TOE BONE GRAFTING
|
Facility
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2959867
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
TOE BONE GRAFTING
|
Facility
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2959867
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
TOE CREST LG LEFT 6505-0
|
Facility
IP
|
$151.00
|
|
| Hospital Charge Code |
2970998
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
TOE CREST LG LEFT 6505-0
|
Facility
OP
|
$151.00
|
|
| Hospital Charge Code |
2970998
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
TOE CREST LG RT 6504-9
|
Facility
OP
|
$151.00
|
|
| Hospital Charge Code |
2970997
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
TOE CREST LG RT 6504-9
|
Facility
IP
|
$151.00
|
|
| Hospital Charge Code |
2970997
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
TOE CREST MEDIUM LEFT 31375
|
Facility
OP
|
$156.00
|
|
| Hospital Charge Code |
2971102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
TOE CREST MEDIUM LEFT 31375
|
Facility
IP
|
$156.00
|
|
| Hospital Charge Code |
2971102
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
TOE CREST MEDIUM RIGHT 31372
|
Facility
IP
|
$156.00
|
|
| Hospital Charge Code |
2971101
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
TOE CREST MEDIUM RIGHT 31372
|
Facility
OP
|
$156.00
|
|
| Hospital Charge Code |
2971101
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$624.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
