|
WAIS IV RESPONSE BOOKLET 2
|
Facility
OP
|
$940.00
|
|
| Hospital Charge Code |
2971755
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$263.20 |
| Max. Negotiated Rate |
$3,760.00 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$808.40
|
| Rate for Payer: Aetna Managed Medicare |
$263.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$611.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$451.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$526.02
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$705.00
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$611.00
|
| Rate for Payer: Quartz Medicare Advantage |
$564.00
|
| Rate for Payer: The Alliance Commercial |
$3,760.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
WAIS IV RESPONSE BOOKLET 2
|
Facility
IP
|
$940.00
|
|
| Hospital Charge Code |
2971755
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$460.60 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$846.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$498.20
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Health EOS Commercial |
$836.60
|
| Rate for Payer: HFN Commercial |
$864.80
|
| Rate for Payer: Multiplan Commercial |
$752.00
|
| Rate for Payer: NAPHCARE Commercial |
$564.00
|
| Rate for Payer: Preferred Network Access Commercial |
$864.80
|
| Rate for Payer: Quartz Beloit One Network |
$460.60
|
| Rate for Payer: Quartz Commercial |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$517.00
|
| Rate for Payer: WPS Commercial |
$696.26
|
|
|
WALKER CAM #L4360
|
Facility
OP
|
$3,075.00
|
|
| Hospital Charge Code |
2974046
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$861.00 |
| Max. Negotiated Rate |
$12,300.00 |
| Rate for Payer: Aetna Commercial |
$2,767.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,644.50
|
| Rate for Payer: Aetna Managed Medicare |
$861.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,998.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,537.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,476.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.75
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$2,829.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,720.77
|
| Rate for Payer: Health EOS Commercial |
$2,736.75
|
| Rate for Payer: HFN Commercial |
$2,829.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,306.25
|
| Rate for Payer: Multiplan Commercial |
$2,460.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,845.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,829.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.75
|
| Rate for Payer: Quartz Commercial |
$1,998.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,845.00
|
| Rate for Payer: The Alliance Commercial |
$12,300.00
|
| Rate for Payer: WEA Trust Commercial |
$1,691.25
|
| Rate for Payer: WPS Commercial |
$2,277.65
|
|
|
WALKER CAM #L4360
|
Facility
IP
|
$3,075.00
|
|
| Hospital Charge Code |
2974046
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,506.75 |
| Max. Negotiated Rate |
$2,829.00 |
| Rate for Payer: Aetna Commercial |
$2,767.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,629.75
|
| Rate for Payer: Cash Price |
$922.50
|
| Rate for Payer: Cigna Commercial |
$2,829.00
|
| Rate for Payer: Health EOS Commercial |
$2,736.75
|
| Rate for Payer: HFN Commercial |
$2,829.00
|
| Rate for Payer: Multiplan Commercial |
$2,460.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,845.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,829.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,506.75
|
| Rate for Payer: Quartz Commercial |
$1,845.00
|
| Rate for Payer: WEA Trust Commercial |
$1,691.25
|
| Rate for Payer: WPS Commercial |
$2,277.65
|
|
|
WALKER,INLINE AIR,CLOSED HEEL,M 15490006
|
Facility
OP
|
$1,000.00
|
|
| Hospital Charge Code |
2974607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$900.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$860.00
|
| Rate for Payer: Aetna Managed Medicare |
$280.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$650.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$500.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$920.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$559.60
|
| Rate for Payer: Health EOS Commercial |
$890.00
|
| Rate for Payer: HFN Commercial |
$920.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$750.00
|
| Rate for Payer: Multiplan Commercial |
$800.00
|
| Rate for Payer: NAPHCARE Commercial |
$600.00
|
| Rate for Payer: Preferred Network Access Commercial |
$920.00
|
| Rate for Payer: Quartz Beloit One Network |
$490.00
|
| Rate for Payer: Quartz Commercial |
$650.00
|
| Rate for Payer: Quartz Medicare Advantage |
$600.00
|
| Rate for Payer: The Alliance Commercial |
$4,000.00
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
WALKER,INLINE AIR,CLOSED HEEL,M 15490006
|
Facility
IP
|
$1,000.00
|
|
| Hospital Charge Code |
2974607
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: Aetna Commercial |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$920.00
|
| Rate for Payer: Health EOS Commercial |
$890.00
|
| Rate for Payer: HFN Commercial |
$920.00
|
| Rate for Payer: Multiplan Commercial |
$800.00
|
| Rate for Payer: NAPHCARE Commercial |
$600.00
|
| Rate for Payer: Preferred Network Access Commercial |
$920.00
|
| Rate for Payer: Quartz Beloit One Network |
$490.00
|
| Rate for Payer: Quartz Commercial |
$600.00
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
WALKER INLINE OPEN HEEL SMALL
|
Facility
OP
|
$999.00
|
|
| Hospital Charge Code |
2974606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$279.72 |
| Max. Negotiated Rate |
$3,996.00 |
| Rate for Payer: Aetna Commercial |
$899.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$859.14
|
| Rate for Payer: Aetna Managed Medicare |
$279.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$649.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$499.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$479.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$529.47
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$919.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$559.04
|
| Rate for Payer: Health EOS Commercial |
$889.11
|
| Rate for Payer: HFN Commercial |
$919.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$749.25
|
| Rate for Payer: Multiplan Commercial |
$799.20
|
| Rate for Payer: NAPHCARE Commercial |
$599.40
|
| Rate for Payer: Preferred Network Access Commercial |
$919.08
|
| Rate for Payer: Quartz Beloit One Network |
$489.51
|
| Rate for Payer: Quartz Commercial |
$649.35
|
| Rate for Payer: Quartz Medicare Advantage |
$599.40
|
| Rate for Payer: The Alliance Commercial |
$3,996.00
|
| Rate for Payer: WEA Trust Commercial |
$549.45
|
| Rate for Payer: WPS Commercial |
$739.96
|
|
|
WALKER INLINE OPEN HEEL SMALL
|
Facility
IP
|
$999.00
|
|
| Hospital Charge Code |
2974606
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$489.51 |
| Max. Negotiated Rate |
$919.08 |
| Rate for Payer: Aetna Commercial |
$899.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$529.47
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$919.08
|
| Rate for Payer: Health EOS Commercial |
$889.11
|
| Rate for Payer: HFN Commercial |
$919.08
|
| Rate for Payer: Multiplan Commercial |
$799.20
|
| Rate for Payer: NAPHCARE Commercial |
$599.40
|
| Rate for Payer: Preferred Network Access Commercial |
$919.08
|
| Rate for Payer: Quartz Beloit One Network |
$489.51
|
| Rate for Payer: Quartz Commercial |
$599.40
|
| Rate for Payer: WEA Trust Commercial |
$549.45
|
| Rate for Payer: WPS Commercial |
$739.96
|
|
|
WALKER PNEUMANTIC AIR SMALL 15490005
|
Facility
IP
|
$1,000.00
|
|
| Hospital Charge Code |
2974605
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: Aetna Commercial |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$920.00
|
| Rate for Payer: Health EOS Commercial |
$890.00
|
| Rate for Payer: HFN Commercial |
$920.00
|
| Rate for Payer: Multiplan Commercial |
$800.00
|
| Rate for Payer: NAPHCARE Commercial |
$600.00
|
| Rate for Payer: Preferred Network Access Commercial |
$920.00
|
| Rate for Payer: Quartz Beloit One Network |
$490.00
|
| Rate for Payer: Quartz Commercial |
$600.00
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
WALKER PNEUMANTIC AIR SMALL 15490005
|
Facility
OP
|
$1,000.00
|
|
| Hospital Charge Code |
2974605
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$900.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$860.00
|
| Rate for Payer: Aetna Managed Medicare |
$280.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$650.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$500.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$920.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$559.60
|
| Rate for Payer: Health EOS Commercial |
$890.00
|
| Rate for Payer: HFN Commercial |
$920.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$750.00
|
| Rate for Payer: Multiplan Commercial |
$800.00
|
| Rate for Payer: NAPHCARE Commercial |
$600.00
|
| Rate for Payer: Preferred Network Access Commercial |
$920.00
|
| Rate for Payer: Quartz Beloit One Network |
$490.00
|
| Rate for Payer: Quartz Commercial |
$650.00
|
| Rate for Payer: Quartz Medicare Advantage |
$600.00
|
| Rate for Payer: The Alliance Commercial |
$4,000.00
|
| Rate for Payer: WEA Trust Commercial |
$550.00
|
| Rate for Payer: WPS Commercial |
$740.70
|
|
|
WALKER PNEUMAT AIR LG 15490067
|
Facility
OP
|
$991.00
|
|
| Hospital Charge Code |
2974604
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.48 |
| Max. Negotiated Rate |
$3,964.00 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Aetna Managed Medicare |
$277.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$644.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.56
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.25
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$644.15
|
| Rate for Payer: Quartz Medicare Advantage |
$594.60
|
| Rate for Payer: The Alliance Commercial |
$3,964.00
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
WALKER PNEUMAT AIR LG 15490067
|
Facility
IP
|
$991.00
|
|
| Hospital Charge Code |
2974604
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$485.59 |
| Max. Negotiated Rate |
$911.72 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$594.60
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
WALKERS & CANES-SP #11458
|
Facility
OP
|
$81.00
|
|
| Hospital Charge Code |
2974082
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
WALKERS & CANES-SP #11458
|
Facility
IP
|
$81.00
|
|
| Hospital Charge Code |
2974082
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
WAND HALO COBLATION WEREWOLF (T & A) 72290134
|
Facility
IP
|
$3,314.00
|
|
| Hospital Charge Code |
5977632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,623.86 |
| Max. Negotiated Rate |
$3,048.88 |
| Rate for Payer: Aetna Commercial |
$2,982.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,756.42
|
| Rate for Payer: Cash Price |
$994.20
|
| Rate for Payer: Cigna Commercial |
$3,048.88
|
| Rate for Payer: Health EOS Commercial |
$2,949.46
|
| Rate for Payer: HFN Commercial |
$3,048.88
|
| Rate for Payer: Multiplan Commercial |
$2,651.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,988.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,048.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,623.86
|
| Rate for Payer: Quartz Commercial |
$1,988.40
|
| Rate for Payer: WEA Trust Commercial |
$1,822.70
|
| Rate for Payer: WPS Commercial |
$2,454.68
|
|
|
WAND HALO COBLATION WEREWOLF (T & A) 72290134
|
Facility
OP
|
$3,314.00
|
|
| Hospital Charge Code |
5977632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$927.92 |
| Max. Negotiated Rate |
$13,256.00 |
| Rate for Payer: Aetna Commercial |
$2,982.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,850.04
|
| Rate for Payer: Aetna Managed Medicare |
$927.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,154.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,657.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,590.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,756.42
|
| Rate for Payer: Cash Price |
$994.20
|
| Rate for Payer: Cigna Commercial |
$3,048.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,854.51
|
| Rate for Payer: Health EOS Commercial |
$2,949.46
|
| Rate for Payer: HFN Commercial |
$3,048.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,485.50
|
| Rate for Payer: Multiplan Commercial |
$2,651.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,988.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,048.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,623.86
|
| Rate for Payer: Quartz Commercial |
$2,154.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,988.40
|
| Rate for Payer: The Alliance Commercial |
$13,256.00
|
| Rate for Payer: WEA Trust Commercial |
$1,822.70
|
| Rate for Payer: WPS Commercial |
$2,454.68
|
|
|
WAND PROCISE MAX COBLATION WITH INTEGRATED CABLE (ADENOID) EICA8898-01
|
Facility
IP
|
$3,037.00
|
|
| Hospital Charge Code |
5861692
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,488.13 |
| Max. Negotiated Rate |
$2,794.04 |
| Rate for Payer: Aetna Commercial |
$2,733.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,609.61
|
| Rate for Payer: Cash Price |
$911.10
|
| Rate for Payer: Cigna Commercial |
$2,794.04
|
| Rate for Payer: Health EOS Commercial |
$2,702.93
|
| Rate for Payer: HFN Commercial |
$2,794.04
|
| Rate for Payer: Multiplan Commercial |
$2,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,822.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,794.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,488.13
|
| Rate for Payer: Quartz Commercial |
$1,822.20
|
| Rate for Payer: WEA Trust Commercial |
$1,670.35
|
| Rate for Payer: WPS Commercial |
$2,249.51
|
|
|
WAND PROCISE MAX COBLATION WITH INTEGRATED CABLE (ADENOID) EICA8898-01
|
Facility
OP
|
$3,037.00
|
|
| Hospital Charge Code |
5861692
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$850.36 |
| Max. Negotiated Rate |
$12,148.00 |
| Rate for Payer: Aetna Commercial |
$2,733.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,611.82
|
| Rate for Payer: Aetna Managed Medicare |
$850.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,974.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,518.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,457.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,609.61
|
| Rate for Payer: Cash Price |
$911.10
|
| Rate for Payer: Cigna Commercial |
$2,794.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,699.51
|
| Rate for Payer: Health EOS Commercial |
$2,702.93
|
| Rate for Payer: HFN Commercial |
$2,794.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,277.75
|
| Rate for Payer: Multiplan Commercial |
$2,429.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,822.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,794.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,488.13
|
| Rate for Payer: Quartz Commercial |
$1,974.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,822.20
|
| Rate for Payer: The Alliance Commercial |
$12,148.00
|
| Rate for Payer: WEA Trust Commercial |
$1,670.35
|
| Rate for Payer: WPS Commercial |
$2,249.51
|
|
|
WAND PROCISE XP WITH INTEGRATED CABLES (T&A) EICA8872-01
|
Facility
OP
|
$3,125.00
|
|
| Hospital Charge Code |
5415485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$12,500.00 |
| Rate for Payer: Aetna Commercial |
$2,812.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,687.50
|
| Rate for Payer: Aetna Managed Medicare |
$875.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,031.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,562.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,500.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,656.25
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$2,875.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,748.75
|
| Rate for Payer: Health EOS Commercial |
$2,781.25
|
| Rate for Payer: HFN Commercial |
$2,875.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,343.75
|
| Rate for Payer: Multiplan Commercial |
$2,500.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,875.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,875.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,531.25
|
| Rate for Payer: Quartz Commercial |
$2,031.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,875.00
|
| Rate for Payer: The Alliance Commercial |
$12,500.00
|
| Rate for Payer: WEA Trust Commercial |
$1,718.75
|
| Rate for Payer: WPS Commercial |
$2,314.69
|
|
|
WAND PROCISE XP WITH INTEGRATED CABLES (T&A) EICA8872-01
|
Facility
IP
|
$3,125.00
|
|
| Hospital Charge Code |
5415485
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,531.25 |
| Max. Negotiated Rate |
$2,875.00 |
| Rate for Payer: Aetna Commercial |
$2,812.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,656.25
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$2,875.00
|
| Rate for Payer: Health EOS Commercial |
$2,781.25
|
| Rate for Payer: HFN Commercial |
$2,875.00
|
| Rate for Payer: Multiplan Commercial |
$2,500.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,875.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,875.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,531.25
|
| Rate for Payer: Quartz Commercial |
$1,875.00
|
| Rate for Payer: WEA Trust Commercial |
$1,718.75
|
| Rate for Payer: WPS Commercial |
$2,314.69
|
|
|
WAND REFLEX ULTRA PLASMA COBLATION PTR (SINUS) EICA4835-01
|
Facility
OP
|
$2,570.00
|
|
| Hospital Charge Code |
3301462
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$719.60 |
| Max. Negotiated Rate |
$10,280.00 |
| Rate for Payer: Aetna Commercial |
$2,313.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,210.20
|
| Rate for Payer: Aetna Managed Medicare |
$719.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,670.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,285.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,233.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,362.10
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$2,364.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,438.17
|
| Rate for Payer: Health EOS Commercial |
$2,287.30
|
| Rate for Payer: HFN Commercial |
$2,364.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,927.50
|
| Rate for Payer: Multiplan Commercial |
$2,056.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,542.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,364.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,259.30
|
| Rate for Payer: Quartz Commercial |
$1,670.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,542.00
|
| Rate for Payer: The Alliance Commercial |
$10,280.00
|
| Rate for Payer: WEA Trust Commercial |
$1,413.50
|
| Rate for Payer: WPS Commercial |
$1,903.60
|
|
|
WAND REFLEX ULTRA PLASMA COBLATION PTR (SINUS) EICA4835-01
|
Facility
IP
|
$2,570.00
|
|
| Hospital Charge Code |
3301462
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,259.30 |
| Max. Negotiated Rate |
$2,364.40 |
| Rate for Payer: Aetna Commercial |
$2,313.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,362.10
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$2,364.40
|
| Rate for Payer: Health EOS Commercial |
$2,287.30
|
| Rate for Payer: HFN Commercial |
$2,364.40
|
| Rate for Payer: Multiplan Commercial |
$2,056.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,542.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,364.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,259.30
|
| Rate for Payer: Quartz Commercial |
$1,542.00
|
| Rate for Payer: WEA Trust Commercial |
$1,413.50
|
| Rate for Payer: WPS Commercial |
$1,903.60
|
|
|
Warfarin, Serum/Plasma
|
Facility
IP
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1038936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Warfarin, Serum/Plasma
|
Facility
OP
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1038936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Warfarin, Serum/Plasma
|
Professional
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1038936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$73.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$82.02
|
|
