|
BASKET ZERO TIP KNOT 2.4FR X 120CM M0063901010
|
Facility
|
IP
|
$2,792.00
|
|
| Hospital Charge Code |
4520078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,368.08 |
| Max. Negotiated Rate |
$2,568.64 |
| Rate for Payer: Aetna Commercial |
$2,512.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,401.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,479.76
|
| Rate for Payer: Cash Price |
$837.60
|
| Rate for Payer: Cigna Commercial |
$2,568.64
|
| Rate for Payer: Health EOS Commercial |
$2,484.88
|
| Rate for Payer: HFN Commercial |
$2,568.64
|
| Rate for Payer: Multiplan Commercial |
$2,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,675.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,568.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,368.08
|
| Rate for Payer: Quartz Commercial |
$1,675.20
|
| Rate for Payer: WEA Trust Commercial |
$1,535.60
|
| Rate for Payer: WPS Commercial |
$2,068.03
|
|
|
BASKET ZERO TIP KNOT 2.4FR X 120CM M0063901010
|
Facility
|
OP
|
$2,792.00
|
|
| Hospital Charge Code |
4520078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.76 |
| Max. Negotiated Rate |
$11,168.00 |
| Rate for Payer: Aetna Commercial |
$2,512.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,401.12
|
| Rate for Payer: Aetna Managed Medicare |
$781.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,814.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,396.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,340.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,479.76
|
| Rate for Payer: Cash Price |
$837.60
|
| Rate for Payer: Cigna Commercial |
$2,568.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,562.40
|
| Rate for Payer: Health EOS Commercial |
$2,484.88
|
| Rate for Payer: HFN Commercial |
$2,568.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,094.00
|
| Rate for Payer: Multiplan Commercial |
$2,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,675.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,568.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,368.08
|
| Rate for Payer: Quartz Commercial |
$1,814.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,675.20
|
| Rate for Payer: The Alliance Commercial |
$11,168.00
|
| Rate for Payer: WEA Trust Commercial |
$1,535.60
|
| Rate for Payer: WPS Commercial |
$2,068.03
|
|
|
BATH SITZ MAUVE
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
2969213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$67.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.50
|
| Rate for Payer: Aetna Managed Medicare |
$21.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.75
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.97
|
| Rate for Payer: Health EOS Commercial |
$66.75
|
| Rate for Payer: HFN Commercial |
$69.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: NAPHCARE Commercial |
$45.00
|
| Rate for Payer: Preferred Network Access Commercial |
$69.00
|
| Rate for Payer: Quartz Beloit One Network |
$36.75
|
| Rate for Payer: Quartz Commercial |
$48.75
|
| Rate for Payer: Quartz Medicare Advantage |
$45.00
|
| Rate for Payer: The Alliance Commercial |
$300.00
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
BATH SITZ MAUVE
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
2969213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$67.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.75
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$66.75
|
| Rate for Payer: HFN Commercial |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$60.00
|
| Rate for Payer: NAPHCARE Commercial |
$45.00
|
| Rate for Payer: Preferred Network Access Commercial |
$69.00
|
| Rate for Payer: Quartz Beloit One Network |
$36.75
|
| Rate for Payer: Quartz Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$41.25
|
| Rate for Payer: WPS Commercial |
$55.55
|
|
|
Battery for Hearing Device
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
3243657
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: United Healthcare PPO |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Battery for Hearing Device
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
3243657
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.60
|
| Rate for Payer: Health EOS Commercial |
$32.76
|
| Rate for Payer: HFN Commercial |
$34.20
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.20
|
| Rate for Payer: Quartz Beloit One Network |
$15.84
|
| Rate for Payer: Quartz Commercial |
$20.52
|
| Rate for Payer: The Alliance Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Battery for Hearing Device
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
3243657
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Baxter 1.5% 2L Dianel Ultrabag
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
3603566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Baxter 1.5% 2L Dianel Ultrabag
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
3603566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$24.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$51.60
|
| Rate for Payer: The Alliance Commercial |
$344.00
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Baxter Mini Caps
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3603564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Baxter Mini Caps
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3603564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Baxter Transfer Set
|
Facility
|
IP
|
$379.00
|
|
| Hospital Charge Code |
3603565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$185.71 |
| Max. Negotiated Rate |
$348.68 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$227.40
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
Baxter Transfer Set
|
Facility
|
OP
|
$379.00
|
|
| Hospital Charge Code |
3603565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$106.12 |
| Max. Negotiated Rate |
$1,516.00 |
| Rate for Payer: Aetna Commercial |
$341.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.94
|
| Rate for Payer: Aetna Managed Medicare |
$106.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$246.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$189.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$181.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.87
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$348.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.09
|
| Rate for Payer: Health EOS Commercial |
$337.31
|
| Rate for Payer: HFN Commercial |
$348.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.25
|
| Rate for Payer: Multiplan Commercial |
$303.20
|
| Rate for Payer: NAPHCARE Commercial |
$227.40
|
| Rate for Payer: Preferred Network Access Commercial |
$348.68
|
| Rate for Payer: Quartz Beloit One Network |
$185.71
|
| Rate for Payer: Quartz Commercial |
$246.35
|
| Rate for Payer: Quartz Medicare Advantage |
$227.40
|
| Rate for Payer: The Alliance Commercial |
$1,516.00
|
| Rate for Payer: WEA Trust Commercial |
$208.45
|
| Rate for Payer: WPS Commercial |
$280.73
|
|
|
BCE Abdomen Biopsy
|
Facility
|
IP
|
$1,741.00
|
|
|
Service Code
|
CPT 49180 TC
|
| Hospital Charge Code |
5418646
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$853.09 |
| Max. Negotiated Rate |
$1,601.72 |
| Rate for Payer: Aetna Commercial |
$1,566.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,497.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$922.73
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,601.72
|
| Rate for Payer: Health EOS Commercial |
$1,549.49
|
| Rate for Payer: HFN Commercial |
$1,601.72
|
| Rate for Payer: Multiplan Commercial |
$1,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,044.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,601.72
|
| Rate for Payer: Quartz Beloit One Network |
$853.09
|
| Rate for Payer: Quartz Commercial |
$1,044.60
|
| Rate for Payer: WEA Trust Commercial |
$957.55
|
| Rate for Payer: WPS Commercial |
$1,289.56
|
|
|
BCE Abdomen Biopsy
|
Facility
|
OP
|
$1,741.00
|
|
|
Service Code
|
CPT 49180 TC
|
| Hospital Charge Code |
5418646
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$487.48 |
| Max. Negotiated Rate |
$6,964.00 |
| Rate for Payer: Aetna Commercial |
$1,566.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,497.26
|
| Rate for Payer: Aetna Managed Medicare |
$487.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$922.73
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,601.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$974.26
|
| Rate for Payer: Health EOS Commercial |
$1,549.49
|
| Rate for Payer: HFN Commercial |
$1,601.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,305.75
|
| Rate for Payer: Multiplan Commercial |
$1,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,044.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,601.72
|
| Rate for Payer: Quartz Beloit One Network |
$853.09
|
| Rate for Payer: Quartz Commercial |
$1,131.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,044.60
|
| Rate for Payer: The Alliance Commercial |
$6,964.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$957.55
|
| Rate for Payer: WPS Commercial |
$1,289.56
|
|
|
BCE Abdomen Biopsy
|
Professional
|
Both
|
$1,741.00
|
|
|
Service Code
|
CPT 49180 TC
|
| Hospital Charge Code |
5418646
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$766.04 |
| Max. Negotiated Rate |
$1,653.95 |
| Rate for Payer: Aetna Commercial |
$1,653.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,497.26
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cash Price |
$522.30
|
| Rate for Payer: Cigna Commercial |
$1,653.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$870.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,044.60
|
| Rate for Payer: Health EOS Commercial |
$1,584.31
|
| Rate for Payer: HFN Commercial |
$1,653.95
|
| Rate for Payer: Multiplan Commercial |
$1,392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,653.95
|
| Rate for Payer: Quartz Beloit One Network |
$766.04
|
| Rate for Payer: Quartz Commercial |
$992.37
|
| Rate for Payer: The Alliance Commercial |
$870.50
|
| Rate for Payer: WEA Trust Commercial |
$957.55
|
| Rate for Payer: WPS Commercial |
$1,289.56
|
|
|
BCE Asp/Inj, Thyroid Cyst
|
Facility
|
IP
|
$671.00
|
|
|
Service Code
|
CPT 60300 TC
|
| Hospital Charge Code |
5484990
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$328.79 |
| Max. Negotiated Rate |
$617.32 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$402.60
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$402.60
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE Asp/Inj, Thyroid Cyst
|
Professional
|
Both
|
$671.00
|
|
|
Service Code
|
CPT 60300 TC
|
| Hospital Charge Code |
5484990
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$295.24 |
| Max. Negotiated Rate |
$637.45 |
| Rate for Payer: Aetna Commercial |
$637.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$637.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$335.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$402.60
|
| Rate for Payer: Health EOS Commercial |
$610.61
|
| Rate for Payer: HFN Commercial |
$637.45
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.45
|
| Rate for Payer: Quartz Beloit One Network |
$295.24
|
| Rate for Payer: Quartz Commercial |
$382.47
|
| Rate for Payer: The Alliance Commercial |
$335.50
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE Asp/Inj, Thyroid Cyst
|
Facility
|
OP
|
$671.00
|
|
|
Service Code
|
CPT 60300 TC
|
| Hospital Charge Code |
5484990
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$187.88 |
| Max. Negotiated Rate |
$2,684.00 |
| Rate for Payer: Aetna Commercial |
$603.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.06
|
| Rate for Payer: Aetna Managed Medicare |
$187.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$436.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$335.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$355.63
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$617.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.49
|
| Rate for Payer: Health EOS Commercial |
$597.19
|
| Rate for Payer: HFN Commercial |
$617.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.25
|
| Rate for Payer: Multiplan Commercial |
$536.80
|
| Rate for Payer: NAPHCARE Commercial |
$402.60
|
| Rate for Payer: Preferred Network Access Commercial |
$617.32
|
| Rate for Payer: Quartz Beloit One Network |
$328.79
|
| Rate for Payer: Quartz Commercial |
$436.15
|
| Rate for Payer: Quartz Medicare Advantage |
$402.60
|
| Rate for Payer: The Alliance Commercial |
$2,684.00
|
| Rate for Payer: WEA Trust Commercial |
$369.05
|
| Rate for Payer: WPS Commercial |
$497.01
|
|
|
BCE Axumin
|
Facility
|
OP
|
$1,163.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
5454652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$325.64 |
| Max. Negotiated Rate |
$4,652.00 |
| Rate for Payer: Aetna Commercial |
$1,046.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.18
|
| Rate for Payer: Aetna Managed Medicare |
$325.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$755.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$581.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$558.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.39
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,069.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$650.81
|
| Rate for Payer: Health EOS Commercial |
$1,035.07
|
| Rate for Payer: HFN Commercial |
$1,069.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$872.25
|
| Rate for Payer: Multiplan Commercial |
$930.40
|
| Rate for Payer: NAPHCARE Commercial |
$697.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,069.96
|
| Rate for Payer: Quartz Beloit One Network |
$569.87
|
| Rate for Payer: Quartz Commercial |
$755.95
|
| Rate for Payer: Quartz Medicare Advantage |
$697.80
|
| Rate for Payer: The Alliance Commercial |
$4,652.00
|
| Rate for Payer: WEA Trust Commercial |
$639.65
|
| Rate for Payer: WPS Commercial |
$861.43
|
|
|
BCE Axumin
|
Professional
|
Both
|
$1,163.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
5454652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$511.72 |
| Max. Negotiated Rate |
$1,104.85 |
| Rate for Payer: Aetna Commercial |
$1,104.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.18
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,104.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$581.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$697.80
|
| Rate for Payer: Health EOS Commercial |
$1,058.33
|
| Rate for Payer: HFN Commercial |
$1,104.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$701.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$701.68
|
| Rate for Payer: Multiplan Commercial |
$930.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,104.85
|
| Rate for Payer: Quartz Beloit One Network |
$511.72
|
| Rate for Payer: Quartz Commercial |
$662.91
|
| Rate for Payer: The Alliance Commercial |
$581.50
|
| Rate for Payer: WEA Trust Commercial |
$639.65
|
| Rate for Payer: WPS Commercial |
$861.43
|
|
|
BCE Axumin
|
Facility
|
IP
|
$1,163.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
5454652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$569.87 |
| Max. Negotiated Rate |
$1,069.96 |
| Rate for Payer: Aetna Commercial |
$1,046.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.39
|
| Rate for Payer: Cash Price |
$348.90
|
| Rate for Payer: Cigna Commercial |
$1,069.96
|
| Rate for Payer: Health EOS Commercial |
$1,035.07
|
| Rate for Payer: HFN Commercial |
$1,069.96
|
| Rate for Payer: Multiplan Commercial |
$930.40
|
| Rate for Payer: NAPHCARE Commercial |
$697.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,069.96
|
| Rate for Payer: Quartz Beloit One Network |
$569.87
|
| Rate for Payer: Quartz Commercial |
$697.80
|
| Rate for Payer: WEA Trust Commercial |
$639.65
|
| Rate for Payer: WPS Commercial |
$861.43
|
|
|
BCE Biopsy Bone
|
Facility
|
IP
|
$4,258.00
|
|
|
Service Code
|
CPT 20220 TC
|
| Hospital Charge Code |
5518669
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,086.42 |
| Max. Negotiated Rate |
$3,917.36 |
| Rate for Payer: Aetna Commercial |
$3,832.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,661.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,256.74
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cigna Commercial |
$3,917.36
|
| Rate for Payer: Health EOS Commercial |
$3,789.62
|
| Rate for Payer: HFN Commercial |
$3,917.36
|
| Rate for Payer: Multiplan Commercial |
$3,406.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,554.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,917.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,086.42
|
| Rate for Payer: Quartz Commercial |
$2,554.80
|
| Rate for Payer: WEA Trust Commercial |
$2,341.90
|
| Rate for Payer: WPS Commercial |
$3,153.90
|
|
|
BCE Biopsy Bone
|
Professional
|
Both
|
$4,258.00
|
|
|
Service Code
|
CPT 20220 TC
|
| Hospital Charge Code |
5518669
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,873.52 |
| Max. Negotiated Rate |
$4,045.10 |
| Rate for Payer: Aetna Commercial |
$4,045.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,661.88
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cigna Commercial |
$4,045.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,129.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,554.80
|
| Rate for Payer: Health EOS Commercial |
$3,874.78
|
| Rate for Payer: HFN Commercial |
$4,045.10
|
| Rate for Payer: Multiplan Commercial |
$3,406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,045.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,873.52
|
| Rate for Payer: Quartz Commercial |
$2,427.06
|
| Rate for Payer: The Alliance Commercial |
$2,129.00
|
| Rate for Payer: WEA Trust Commercial |
$2,341.90
|
| Rate for Payer: WPS Commercial |
$3,153.90
|
|
|
BCE Biopsy Bone
|
Facility
|
OP
|
$4,258.00
|
|
|
Service Code
|
CPT 20220 TC
|
| Hospital Charge Code |
5518669
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,192.24 |
| Max. Negotiated Rate |
$17,032.00 |
| Rate for Payer: Aetna Commercial |
$3,832.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,661.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,192.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,256.74
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cash Price |
$1,277.40
|
| Rate for Payer: Cigna Commercial |
$3,917.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,382.78
|
| Rate for Payer: Health EOS Commercial |
$3,789.62
|
| Rate for Payer: HFN Commercial |
$3,917.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,193.50
|
| Rate for Payer: Multiplan Commercial |
$3,406.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,554.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,917.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,086.42
|
| Rate for Payer: Quartz Commercial |
$2,767.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,554.80
|
| Rate for Payer: The Alliance Commercial |
$17,032.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,341.90
|
| Rate for Payer: WPS Commercial |
$3,153.90
|
|
