|
Abrysvo RSV vaccine preF A-preF B, recombinant 90678
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT 90678
|
| Hospital Charge Code |
6224208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.62 |
| Max. Negotiated Rate |
$310.96 |
| Rate for Payer: Aetna Commercial |
$304.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$290.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.14
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Cigna Commercial |
$310.96
|
| Rate for Payer: Health EOS Commercial |
$300.82
|
| Rate for Payer: HFN Commercial |
$310.96
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: NAPHCARE Commercial |
$202.80
|
| Rate for Payer: Preferred Network Access Commercial |
$310.96
|
| Rate for Payer: Quartz Beloit One Network |
$165.62
|
| Rate for Payer: Quartz Commercial |
$202.80
|
| Rate for Payer: WEA Trust Commercial |
$185.90
|
| Rate for Payer: WPS Commercial |
$250.36
|
|
|
Abrysvo RSV vaccine preF A-preF B, recombinant 90678
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT 90678
|
| Hospital Charge Code |
6224208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$1,352.00 |
| Rate for Payer: Aetna Commercial |
$304.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$290.68
|
| Rate for Payer: Aetna Managed Medicare |
$94.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$219.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.14
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Cigna Commercial |
$310.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.14
|
| Rate for Payer: Health EOS Commercial |
$300.82
|
| Rate for Payer: HFN Commercial |
$310.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$253.50
|
| Rate for Payer: Multiplan Commercial |
$270.40
|
| Rate for Payer: NAPHCARE Commercial |
$202.80
|
| Rate for Payer: Preferred Network Access Commercial |
$310.96
|
| Rate for Payer: Quartz Beloit One Network |
$165.62
|
| Rate for Payer: Quartz Commercial |
$219.70
|
| Rate for Payer: Quartz Medicare Advantage |
$202.80
|
| Rate for Payer: The Alliance Commercial |
$1,352.00
|
| Rate for Payer: WEA Trust Commercial |
$185.90
|
| Rate for Payer: WPS Commercial |
$250.36
|
|
|
Abscess Drainage Under XRAY 7598926
|
Professional
|
Both
|
$586.00
|
|
|
Service Code
|
CPT 75989 26
|
| Hospital Charge Code |
3206188
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$192.84 |
| Max. Negotiated Rate |
$556.70 |
| Rate for Payer: Aetna Commercial |
$556.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.96
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$556.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$293.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$351.60
|
| Rate for Payer: Health EOS Commercial |
$533.26
|
| Rate for Payer: HFN Commercial |
$556.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.84
|
| Rate for Payer: Multiplan Commercial |
$468.80
|
| Rate for Payer: Preferred Network Access Commercial |
$556.70
|
| Rate for Payer: Quartz Beloit One Network |
$257.84
|
| Rate for Payer: Quartz Commercial |
$334.02
|
| Rate for Payer: The Alliance Commercial |
$293.00
|
| Rate for Payer: WEA Trust Commercial |
$322.30
|
| Rate for Payer: WPS Commercial |
$434.05
|
|
|
Ab Titer
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
973765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Dean Health Medicaid |
$5.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicaid |
$5.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.35
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicaid |
$5.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$218.25
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WMAP Medicaid |
$5.35
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
Ab Titer
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
973765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.59 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$174.60
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
ACCESSORY BONE REMOVAL
|
Facility
|
OP
|
$1,242.00
|
|
| Hospital Charge Code |
2959776
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$347.76 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,068.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$807.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$621.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$596.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$695.02
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$931.50
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$807.30
|
| Rate for Payer: Quartz Medicare Advantage |
$745.20
|
| Rate for Payer: The Alliance Commercial |
$4,968.00
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
ACCESSORY BONE REMOVAL
|
Facility
|
IP
|
$1,242.00
|
|
| Hospital Charge Code |
2959776
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$608.58 |
| Max. Negotiated Rate |
$1,142.64 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,068.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$745.20
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
ACCESSORY KIT AMS 800 720066-01
|
Facility
|
OP
|
$7,154.00
|
|
| Hospital Charge Code |
5385017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,003.12 |
| Max. Negotiated Rate |
$28,616.00 |
| Rate for Payer: Aetna Commercial |
$6,438.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,152.44
|
| Rate for Payer: Aetna Managed Medicare |
$2,003.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,650.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,577.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,433.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,791.62
|
| Rate for Payer: Cash Price |
$2,146.20
|
| Rate for Payer: Cigna Commercial |
$6,581.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,003.38
|
| Rate for Payer: Health EOS Commercial |
$6,367.06
|
| Rate for Payer: HFN Commercial |
$6,581.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,365.50
|
| Rate for Payer: Multiplan Commercial |
$5,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,292.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,581.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,505.46
|
| Rate for Payer: Quartz Commercial |
$4,650.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,292.40
|
| Rate for Payer: The Alliance Commercial |
$28,616.00
|
| Rate for Payer: WEA Trust Commercial |
$3,934.70
|
| Rate for Payer: WPS Commercial |
$5,298.97
|
|
|
ACCESSORY KIT AMS 800 720066-01
|
Facility
|
IP
|
$7,154.00
|
|
| Hospital Charge Code |
5385017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,505.46 |
| Max. Negotiated Rate |
$6,581.68 |
| Rate for Payer: Aetna Commercial |
$6,438.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,152.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,791.62
|
| Rate for Payer: Cash Price |
$2,146.20
|
| Rate for Payer: Cigna Commercial |
$6,581.68
|
| Rate for Payer: Health EOS Commercial |
$6,367.06
|
| Rate for Payer: HFN Commercial |
$6,581.68
|
| Rate for Payer: Multiplan Commercial |
$5,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,292.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,581.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,505.46
|
| Rate for Payer: Quartz Commercial |
$4,292.40
|
| Rate for Payer: WEA Trust Commercial |
$3,934.70
|
| Rate for Payer: WPS Commercial |
$5,298.97
|
|
|
ACCESSORY KIT TRUCLEAR SUCTION CANISTER (4 JUMPER TUBES/TISSUE SOCK) 7209824
|
Facility
|
IP
|
$483.00
|
|
| Hospital Charge Code |
5563521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$236.67 |
| Max. Negotiated Rate |
$444.36 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$289.80
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
ACCESSORY KIT TRUCLEAR SUCTION CANISTER (4 JUMPER TUBES/TISSUE SOCK) 7209824
|
Facility
|
OP
|
$483.00
|
|
| Hospital Charge Code |
5563521
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$1,932.00 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| Rate for Payer: Aetna Managed Medicare |
$135.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$313.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$241.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.29
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$362.25
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$313.95
|
| Rate for Payer: Quartz Medicare Advantage |
$289.80
|
| Rate for Payer: The Alliance Commercial |
$1,932.00
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
ACCESS SPIKE CLAVE MULTIDOSE VIAL 12007
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2963232
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
ACCESS SPIKE CLAVE MULTIDOSE VIAL 12007
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2963232
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
ACCUMAX 1000 M0068404042
|
Facility
|
IP
|
$5,990.00
|
|
| Hospital Charge Code |
4520036
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,935.10 |
| Max. Negotiated Rate |
$5,510.80 |
| Rate for Payer: Aetna Commercial |
$5,391.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,151.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,174.70
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cigna Commercial |
$5,510.80
|
| Rate for Payer: Health EOS Commercial |
$5,331.10
|
| Rate for Payer: HFN Commercial |
$5,510.80
|
| Rate for Payer: Multiplan Commercial |
$4,792.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,594.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,510.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,935.10
|
| Rate for Payer: Quartz Commercial |
$3,594.00
|
| Rate for Payer: WEA Trust Commercial |
$3,294.50
|
| Rate for Payer: WPS Commercial |
$4,436.79
|
|
|
ACCUMAX 1000 M0068404042
|
Facility
|
OP
|
$5,990.00
|
|
| Hospital Charge Code |
4520036
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,677.20 |
| Max. Negotiated Rate |
$23,960.00 |
| Rate for Payer: Aetna Commercial |
$5,391.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,151.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,677.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,893.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,995.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,875.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,174.70
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Cigna Commercial |
$5,510.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,352.00
|
| Rate for Payer: Health EOS Commercial |
$5,331.10
|
| Rate for Payer: HFN Commercial |
$5,510.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,492.50
|
| Rate for Payer: Multiplan Commercial |
$4,792.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,594.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,510.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,935.10
|
| Rate for Payer: Quartz Commercial |
$3,893.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,594.00
|
| Rate for Payer: The Alliance Commercial |
$23,960.00
|
| Rate for Payer: WEA Trust Commercial |
$3,294.50
|
| Rate for Payer: WPS Commercial |
$4,436.79
|
|
|
ACCUMAX 365 M0068404022
|
Facility
|
OP
|
$3,603.00
|
|
| Hospital Charge Code |
4520033
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,008.84 |
| Max. Negotiated Rate |
$14,412.00 |
| Rate for Payer: Aetna Commercial |
$3,242.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,098.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,008.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,341.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,801.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,729.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,909.59
|
| Rate for Payer: Cash Price |
$1,080.90
|
| Rate for Payer: Cigna Commercial |
$3,314.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,016.24
|
| Rate for Payer: Health EOS Commercial |
$3,206.67
|
| Rate for Payer: HFN Commercial |
$3,314.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,702.25
|
| Rate for Payer: Multiplan Commercial |
$2,882.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,161.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,314.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,765.47
|
| Rate for Payer: Quartz Commercial |
$2,341.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,161.80
|
| Rate for Payer: The Alliance Commercial |
$14,412.00
|
| Rate for Payer: WEA Trust Commercial |
$1,981.65
|
| Rate for Payer: WPS Commercial |
$2,668.74
|
|
|
ACCUMAX 365 M0068404022
|
Facility
|
IP
|
$3,603.00
|
|
| Hospital Charge Code |
4520033
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,765.47 |
| Max. Negotiated Rate |
$3,314.76 |
| Rate for Payer: Aetna Commercial |
$3,242.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,098.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,909.59
|
| Rate for Payer: Cash Price |
$1,080.90
|
| Rate for Payer: Cigna Commercial |
$3,314.76
|
| Rate for Payer: Health EOS Commercial |
$3,206.67
|
| Rate for Payer: HFN Commercial |
$3,314.76
|
| Rate for Payer: Multiplan Commercial |
$2,882.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,161.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,314.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,765.47
|
| Rate for Payer: Quartz Commercial |
$2,161.80
|
| Rate for Payer: WEA Trust Commercial |
$1,981.65
|
| Rate for Payer: WPS Commercial |
$2,668.74
|
|
|
ACCUMAX 550 M0068404032
|
Facility
|
IP
|
$4,750.00
|
|
| Hospital Charge Code |
4520034
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,327.50 |
| Max. Negotiated Rate |
$4,370.00 |
| Rate for Payer: Aetna Commercial |
$4,275.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,085.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,517.50
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,370.00
|
| Rate for Payer: Health EOS Commercial |
$4,227.50
|
| Rate for Payer: HFN Commercial |
$4,370.00
|
| Rate for Payer: Multiplan Commercial |
$3,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,850.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,370.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,327.50
|
| Rate for Payer: Quartz Commercial |
$2,850.00
|
| Rate for Payer: WEA Trust Commercial |
$2,612.50
|
| Rate for Payer: WPS Commercial |
$3,518.32
|
|
|
ACCUMAX 550 M0068404032
|
Facility
|
OP
|
$4,750.00
|
|
| Hospital Charge Code |
4520034
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,330.00 |
| Max. Negotiated Rate |
$19,000.00 |
| Rate for Payer: Aetna Commercial |
$4,275.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,085.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,330.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,087.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,375.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,280.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,517.50
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,370.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,658.10
|
| Rate for Payer: Health EOS Commercial |
$4,227.50
|
| Rate for Payer: HFN Commercial |
$4,370.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,562.50
|
| Rate for Payer: Multiplan Commercial |
$3,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,850.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,370.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,327.50
|
| Rate for Payer: Quartz Commercial |
$3,087.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,850.00
|
| Rate for Payer: The Alliance Commercial |
$19,000.00
|
| Rate for Payer: WEA Trust Commercial |
$2,612.50
|
| Rate for Payer: WPS Commercial |
$3,518.32
|
|
|
AccuType IL28B
|
Professional
|
Both
|
$639.00
|
|
|
Service Code
|
CPT 81400
|
| Hospital Charge Code |
978136
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$225.78 |
| Max. Negotiated Rate |
$607.05 |
| Rate for Payer: Aetna Commercial |
$607.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.54
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$607.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$319.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$383.40
|
| Rate for Payer: Health EOS Commercial |
$581.49
|
| Rate for Payer: HFN Commercial |
$607.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$225.78
|
| Rate for Payer: Multiplan Commercial |
$511.20
|
| Rate for Payer: Preferred Network Access Commercial |
$607.05
|
| Rate for Payer: Quartz Beloit One Network |
$281.16
|
| Rate for Payer: Quartz Commercial |
$364.23
|
| Rate for Payer: The Alliance Commercial |
$319.50
|
| Rate for Payer: WEA Trust Commercial |
$351.45
|
| Rate for Payer: WPS Commercial |
$473.31
|
|
|
AccuType IL28B
|
Facility
|
IP
|
$639.00
|
|
|
Service Code
|
CPT 81400
|
| Hospital Charge Code |
978136
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$313.11 |
| Max. Negotiated Rate |
$587.88 |
| Rate for Payer: Aetna Commercial |
$575.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.67
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$587.88
|
| Rate for Payer: Health EOS Commercial |
$568.71
|
| Rate for Payer: HFN Commercial |
$587.88
|
| Rate for Payer: Multiplan Commercial |
$511.20
|
| Rate for Payer: NAPHCARE Commercial |
$383.40
|
| Rate for Payer: Preferred Network Access Commercial |
$587.88
|
| Rate for Payer: Quartz Beloit One Network |
$313.11
|
| Rate for Payer: Quartz Commercial |
$383.40
|
| Rate for Payer: WEA Trust Commercial |
$351.45
|
| Rate for Payer: WPS Commercial |
$473.31
|
|
|
AccuType IL28B
|
Facility
|
OP
|
$639.00
|
|
|
Service Code
|
CPT 81400
|
| Hospital Charge Code |
978136
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.96 |
| Max. Negotiated Rate |
$587.88 |
| Rate for Payer: Aetna Commercial |
$575.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.54
|
| Rate for Payer: Aetna Managed Medicare |
$63.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.17
|
| Rate for Payer: Anthem Medicaid |
$63.96
|
| Rate for Payer: Anthem Medicare Advantage |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$338.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.96
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$587.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$63.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$357.58
|
| Rate for Payer: Dean Health Medicaid |
$63.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$63.96
|
| Rate for Payer: Health EOS Commercial |
$568.71
|
| Rate for Payer: HFN Commercial |
$587.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.96
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$63.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.96
|
| Rate for Payer: Managed Health Services Medicaid |
$66.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$63.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$511.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.94
|
| Rate for Payer: Preferred Network Access Commercial |
$587.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$63.96
|
| Rate for Payer: Quartz Beloit One Network |
$313.11
|
| Rate for Payer: Quartz Commercial |
$415.35
|
| Rate for Payer: Quartz Medicare Advantage |
$63.96
|
| Rate for Payer: The Alliance Commercial |
$255.84
|
| Rate for Payer: United Healthcare Medicaid |
$63.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.96
|
| Rate for Payer: United Healthcare PPO |
$479.25
|
| Rate for Payer: WEA Trust Commercial |
$351.45
|
| Rate for Payer: Wellcare Medicare |
$63.96
|
| Rate for Payer: WMAP Medicaid |
$63.96
|
| Rate for Payer: WPS Commercial |
$473.31
|
|
|
AccuType IL28B - Interp & Report
|
Facility
|
IP
|
$115.00
|
|
| Hospital Charge Code |
1270802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
AccuType IL28B - Interp & Report
|
Professional
|
Both
|
$115.00
|
|
| Hospital Charge Code |
1270802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$109.25 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$104.65
|
| Rate for Payer: HFN Commercial |
$109.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: Preferred Network Access Commercial |
$109.25
|
| Rate for Payer: Quartz Beloit One Network |
$50.60
|
| Rate for Payer: Quartz Commercial |
$65.55
|
| Rate for Payer: The Alliance Commercial |
$57.50
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
AccuType IL28B - Interp & Report
|
Facility
|
OP
|
$115.00
|
|
| Hospital Charge Code |
1270802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: United Healthcare PPO |
$86.25
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
