|
BOTTLE PREVAC W/TUBING 1000ML SV1000-S/SV1000-NS
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4353486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.10 |
| Max. Negotiated Rate |
$315.74 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Aetna Managed Medicare |
$96.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$171.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$164.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$315.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.06
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$257.40
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: NAPHCARE Commercial |
$205.92
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$223.08
|
| Rate for Payer: Quartz Medicare Advantage |
$205.92
|
| Rate for Payer: The Alliance Commercial |
$250.97
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
BOTTLE PREVAC W/TUBING 1000ML SV1000-S/SV1000-NS
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4353486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.17 |
| Max. Negotiated Rate |
$315.74 |
| Rate for Payer: Aetna Commercial |
$308.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$181.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$315.74
|
| Rate for Payer: Health EOS Commercial |
$305.45
|
| Rate for Payer: HFN Commercial |
$315.74
|
| Rate for Payer: Multiplan Commercial |
$274.56
|
| Rate for Payer: Preferred Network Access Commercial |
$315.74
|
| Rate for Payer: Quartz Beloit One Network |
$168.17
|
| Rate for Payer: Quartz Commercial |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$188.76
|
| Rate for Payer: WPS Commercial |
$254.20
|
|
|
Botulinum toxin 1 U J0585
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$27.08 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Aetna Managed Medicare |
$6.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.49
|
| Rate for Payer: Anthem Medicare Advantage |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.77
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.77
|
| Rate for Payer: Health EOS Commercial |
$15.74
|
| Rate for Payer: HFN Commercial |
$16.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.77
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: NAPHCARE Commercial |
$10.16
|
| Rate for Payer: Preferred Network Access Commercial |
$16.27
|
| Rate for Payer: Quartz Beloit One Network |
$8.66
|
| Rate for Payer: Quartz Commercial |
$11.49
|
| Rate for Payer: Quartz Medicare Advantage |
$6.77
|
| Rate for Payer: The Alliance Commercial |
$27.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.77
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: Wellcare Medicare |
$6.77
|
| Rate for Payer: WPS Commercial |
$16.43
|
|
|
Botulinum toxin 1 U J0585
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.37
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.27
|
| Rate for Payer: Health EOS Commercial |
$15.74
|
| Rate for Payer: HFN Commercial |
$16.27
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: Preferred Network Access Commercial |
$16.27
|
| Rate for Payer: Quartz Beloit One Network |
$8.66
|
| Rate for Payer: Quartz Commercial |
$10.61
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: WPS Commercial |
$13.10
|
|
|
Botulinum toxin 1 U J0585
|
Professional
|
Both
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$18.62 |
| Rate for Payer: Aetna Commercial |
$16.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.20
|
| Rate for Payer: Aetna Managed Medicare |
$6.77
|
| Rate for Payer: Anthem Medicare Advantage |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.77
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.57
|
| Rate for Payer: Health EOS Commercial |
$16.09
|
| Rate for Payer: HFN Commercial |
$16.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.77
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: NAPHCARE Commercial |
$10.16
|
| Rate for Payer: Preferred Network Access Commercial |
$16.80
|
| Rate for Payer: Quartz Beloit One Network |
$7.78
|
| Rate for Payer: Quartz Commercial |
$10.08
|
| Rate for Payer: Quartz Medicare Advantage |
$6.77
|
| Rate for Payer: The Alliance Commercial |
$18.62
|
| Rate for Payer: United Healthcare Medicaid |
$6.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.77
|
| Rate for Payer: WEA Trust Commercial |
$9.72
|
| Rate for Payer: WPS Commercial |
$16.43
|
|
|
BOWL CELL SAVER MINI 70 ML 0291A-00
|
Facility
|
OP
|
$2,288.00
|
|
| Hospital Charge Code |
2962860
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$666.27 |
| Max. Negotiated Rate |
$2,189.16 |
| Rate for Payer: Aetna Commercial |
$2,141.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.39
|
| Rate for Payer: Aetna Managed Medicare |
$666.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,546.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,189.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,142.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.15
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,189.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,331.62
|
| Rate for Payer: Health EOS Commercial |
$2,117.77
|
| Rate for Payer: HFN Commercial |
$2,189.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,784.64
|
| Rate for Payer: Multiplan Commercial |
$1,903.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,427.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,165.96
|
| Rate for Payer: Quartz Commercial |
$1,546.69
|
| Rate for Payer: Quartz Medicare Advantage |
$1,427.71
|
| Rate for Payer: The Alliance Commercial |
$1,189.76
|
| Rate for Payer: WEA Trust Commercial |
$1,308.74
|
| Rate for Payer: WPS Commercial |
$1,762.45
|
|
|
BOWL CELL SAVER MINI 70 ML 0291A-00
|
Facility
|
IP
|
$2,288.00
|
|
| Hospital Charge Code |
2962860
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,165.96 |
| Max. Negotiated Rate |
$2,189.16 |
| Rate for Payer: Aetna Commercial |
$2,141.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.15
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,189.16
|
| Rate for Payer: Health EOS Commercial |
$2,117.77
|
| Rate for Payer: HFN Commercial |
$2,189.16
|
| Rate for Payer: Multiplan Commercial |
$1,903.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,165.96
|
| Rate for Payer: Quartz Commercial |
$1,427.71
|
| Rate for Payer: WEA Trust Commercial |
$1,308.74
|
| Rate for Payer: WPS Commercial |
$1,762.45
|
|
|
BOWL CEMENT MIXEVAC III 0206-015-000
|
Facility
|
OP
|
$944.00
|
|
| Hospital Charge Code |
4089812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$274.89 |
| Max. Negotiated Rate |
$903.22 |
| Rate for Payer: Aetna Commercial |
$883.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$844.31
|
| Rate for Payer: Aetna Managed Medicare |
$274.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$638.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$490.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$471.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.33
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$903.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$549.41
|
| Rate for Payer: Health EOS Commercial |
$873.77
|
| Rate for Payer: HFN Commercial |
$903.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$736.32
|
| Rate for Payer: Multiplan Commercial |
$785.41
|
| Rate for Payer: NAPHCARE Commercial |
$589.06
|
| Rate for Payer: Preferred Network Access Commercial |
$903.22
|
| Rate for Payer: Quartz Beloit One Network |
$481.06
|
| Rate for Payer: Quartz Commercial |
$638.14
|
| Rate for Payer: Quartz Medicare Advantage |
$589.06
|
| Rate for Payer: The Alliance Commercial |
$490.88
|
| Rate for Payer: WEA Trust Commercial |
$539.97
|
| Rate for Payer: WPS Commercial |
$727.16
|
|
|
BOWL CEMENT MIXEVAC III 0206-015-000
|
Facility
|
IP
|
$944.00
|
|
| Hospital Charge Code |
4089812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$481.06 |
| Max. Negotiated Rate |
$903.22 |
| Rate for Payer: Aetna Commercial |
$883.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$844.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.33
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$903.22
|
| Rate for Payer: Health EOS Commercial |
$873.77
|
| Rate for Payer: HFN Commercial |
$903.22
|
| Rate for Payer: Multiplan Commercial |
$785.41
|
| Rate for Payer: Preferred Network Access Commercial |
$903.22
|
| Rate for Payer: Quartz Beloit One Network |
$481.06
|
| Rate for Payer: Quartz Commercial |
$589.06
|
| Rate for Payer: WEA Trust Commercial |
$539.97
|
| Rate for Payer: WPS Commercial |
$727.16
|
|
|
BOWL GUIDEWIRE 2500ML/84 OZ DYNJGUIDEWIRE
|
Facility
|
OP
|
$176.00
|
|
| Hospital Charge Code |
6217079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.25 |
| Max. Negotiated Rate |
$168.40 |
| Rate for Payer: Aetna Commercial |
$164.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$157.41
|
| Rate for Payer: Aetna Managed Medicare |
$51.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.01
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$168.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.43
|
| Rate for Payer: Health EOS Commercial |
$162.91
|
| Rate for Payer: HFN Commercial |
$168.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.28
|
| Rate for Payer: Multiplan Commercial |
$146.43
|
| Rate for Payer: NAPHCARE Commercial |
$109.82
|
| Rate for Payer: Preferred Network Access Commercial |
$168.40
|
| Rate for Payer: Quartz Beloit One Network |
$89.69
|
| Rate for Payer: Quartz Commercial |
$118.98
|
| Rate for Payer: Quartz Medicare Advantage |
$109.82
|
| Rate for Payer: The Alliance Commercial |
$91.52
|
| Rate for Payer: WEA Trust Commercial |
$100.67
|
| Rate for Payer: WPS Commercial |
$135.57
|
|
|
BOWL GUIDEWIRE 2500ML/84 OZ DYNJGUIDEWIRE
|
Facility
|
IP
|
$176.00
|
|
| Hospital Charge Code |
6217079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.69 |
| Max. Negotiated Rate |
$168.40 |
| Rate for Payer: Aetna Commercial |
$164.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$157.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.01
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$168.40
|
| Rate for Payer: Health EOS Commercial |
$162.91
|
| Rate for Payer: HFN Commercial |
$168.40
|
| Rate for Payer: Multiplan Commercial |
$146.43
|
| Rate for Payer: Preferred Network Access Commercial |
$168.40
|
| Rate for Payer: Quartz Beloit One Network |
$89.69
|
| Rate for Payer: Quartz Commercial |
$109.82
|
| Rate for Payer: WEA Trust Commercial |
$100.67
|
| Rate for Payer: WPS Commercial |
$135.57
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$15,607.59
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$13,863.64 |
| Max. Negotiated Rate |
$15,607.59 |
| Rate for Payer: Anthem Medicaid |
$14,945.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,945.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,945.13
|
| Rate for Payer: Dean Health Medicaid |
$14,945.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,863.64
|
| Rate for Payer: Managed Health Services Medicaid |
$15,607.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,945.13
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,945.13
|
| Rate for Payer: United Healthcare Medicaid |
$14,945.13
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$3,945.74
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$3,504.85 |
| Max. Negotiated Rate |
$3,945.74 |
| Rate for Payer: Anthem Medicaid |
$3,778.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,778.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,778.26
|
| Rate for Payer: Dean Health Medicaid |
$3,778.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,504.85
|
| Rate for Payer: Managed Health Services Medicaid |
$3,945.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,778.26
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,778.26
|
| Rate for Payer: United Healthcare Medicaid |
$3,778.26
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$11,223.44
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$9,969.36 |
| Max. Negotiated Rate |
$11,223.44 |
| Rate for Payer: Anthem Medicaid |
$10,747.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,747.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,747.06
|
| Rate for Payer: Dean Health Medicaid |
$10,747.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,969.36
|
| Rate for Payer: Managed Health Services Medicaid |
$11,223.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,747.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,747.06
|
| Rate for Payer: United Healthcare Medicaid |
$10,747.06
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$6,663.92
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$5,919.31 |
| Max. Negotiated Rate |
$6,663.92 |
| Rate for Payer: Anthem Medicaid |
$6,381.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,381.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,381.07
|
| Rate for Payer: Dean Health Medicaid |
$6,381.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,919.31
|
| Rate for Payer: Managed Health Services Medicaid |
$6,663.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,381.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,381.07
|
| Rate for Payer: United Healthcare Medicaid |
$6,381.07
|
|
|
BRACE ANKLE DEROYAL #AB2340-06
|
Facility
|
IP
|
$438.00
|
|
| Hospital Charge Code |
2969578
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$223.20 |
| Max. Negotiated Rate |
$419.08 |
| Rate for Payer: Aetna Commercial |
$409.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$391.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.43
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$419.08
|
| Rate for Payer: Health EOS Commercial |
$405.41
|
| Rate for Payer: HFN Commercial |
$419.08
|
| Rate for Payer: Multiplan Commercial |
$364.42
|
| Rate for Payer: Preferred Network Access Commercial |
$419.08
|
| Rate for Payer: Quartz Beloit One Network |
$223.20
|
| Rate for Payer: Quartz Commercial |
$273.31
|
| Rate for Payer: WEA Trust Commercial |
$250.54
|
| Rate for Payer: WPS Commercial |
$337.39
|
|
|
BRACE ANKLE DEROYAL #AB2340-06
|
Facility
|
OP
|
$438.00
|
|
| Hospital Charge Code |
2969578
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$127.55 |
| Max. Negotiated Rate |
$419.08 |
| Rate for Payer: Aetna Commercial |
$409.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$391.75
|
| Rate for Payer: Aetna Managed Medicare |
$127.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$227.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.43
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$419.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$254.92
|
| Rate for Payer: Health EOS Commercial |
$405.41
|
| Rate for Payer: HFN Commercial |
$419.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$341.64
|
| Rate for Payer: Multiplan Commercial |
$364.42
|
| Rate for Payer: NAPHCARE Commercial |
$273.31
|
| Rate for Payer: Preferred Network Access Commercial |
$419.08
|
| Rate for Payer: Quartz Beloit One Network |
$223.20
|
| Rate for Payer: Quartz Commercial |
$296.09
|
| Rate for Payer: Quartz Medicare Advantage |
$273.31
|
| Rate for Payer: The Alliance Commercial |
$227.76
|
| Rate for Payer: WEA Trust Commercial |
$250.54
|
| Rate for Payer: WPS Commercial |
$337.39
|
|
|
BRACE ANKLE LT SM 02CL
|
Facility
|
OP
|
$417.00
|
|
| Hospital Charge Code |
2974433
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$121.43 |
| Max. Negotiated Rate |
$398.99 |
| Rate for Payer: Aetna Commercial |
$390.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$372.96
|
| Rate for Payer: Aetna Managed Medicare |
$121.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$281.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$216.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$229.85
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$398.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$242.69
|
| Rate for Payer: Health EOS Commercial |
$385.98
|
| Rate for Payer: HFN Commercial |
$398.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$325.26
|
| Rate for Payer: Multiplan Commercial |
$346.94
|
| Rate for Payer: NAPHCARE Commercial |
$260.21
|
| Rate for Payer: Preferred Network Access Commercial |
$398.99
|
| Rate for Payer: Quartz Beloit One Network |
$212.50
|
| Rate for Payer: Quartz Commercial |
$281.89
|
| Rate for Payer: Quartz Medicare Advantage |
$260.21
|
| Rate for Payer: The Alliance Commercial |
$216.84
|
| Rate for Payer: WEA Trust Commercial |
$238.52
|
| Rate for Payer: WPS Commercial |
$321.22
|
|
|
BRACE ANKLE LT SM 02CL
|
Facility
|
IP
|
$417.00
|
|
| Hospital Charge Code |
2974433
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$212.50 |
| Max. Negotiated Rate |
$398.99 |
| Rate for Payer: Aetna Commercial |
$390.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$372.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$229.85
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$398.99
|
| Rate for Payer: Health EOS Commercial |
$385.98
|
| Rate for Payer: HFN Commercial |
$398.99
|
| Rate for Payer: Multiplan Commercial |
$346.94
|
| Rate for Payer: Preferred Network Access Commercial |
$398.99
|
| Rate for Payer: Quartz Beloit One Network |
$212.50
|
| Rate for Payer: Quartz Commercial |
$260.21
|
| Rate for Payer: WEA Trust Commercial |
$238.52
|
| Rate for Payer: WPS Commercial |
$321.22
|
|
|
BRACE ANKLE STANDARD LRG/RT
|
Facility
|
IP
|
$384.00
|
|
| Hospital Charge Code |
2969660
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$195.69 |
| Max. Negotiated Rate |
$367.41 |
| Rate for Payer: Aetna Commercial |
$359.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$343.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.66
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$367.41
|
| Rate for Payer: Health EOS Commercial |
$355.43
|
| Rate for Payer: HFN Commercial |
$367.41
|
| Rate for Payer: Multiplan Commercial |
$319.49
|
| Rate for Payer: Preferred Network Access Commercial |
$367.41
|
| Rate for Payer: Quartz Beloit One Network |
$195.69
|
| Rate for Payer: Quartz Commercial |
$239.62
|
| Rate for Payer: WEA Trust Commercial |
$219.65
|
| Rate for Payer: WPS Commercial |
$295.80
|
|
|
BRACE ANKLE STANDARD LRG/RT
|
Facility
|
OP
|
$384.00
|
|
| Hospital Charge Code |
2969660
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$111.82 |
| Max. Negotiated Rate |
$367.41 |
| Rate for Payer: Aetna Commercial |
$359.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$343.45
|
| Rate for Payer: Aetna Managed Medicare |
$111.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$259.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$199.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$191.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$211.66
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$367.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$223.49
|
| Rate for Payer: Health EOS Commercial |
$355.43
|
| Rate for Payer: HFN Commercial |
$367.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.52
|
| Rate for Payer: Multiplan Commercial |
$319.49
|
| Rate for Payer: NAPHCARE Commercial |
$239.62
|
| Rate for Payer: Preferred Network Access Commercial |
$367.41
|
| Rate for Payer: Quartz Beloit One Network |
$195.69
|
| Rate for Payer: Quartz Commercial |
$259.58
|
| Rate for Payer: Quartz Medicare Advantage |
$239.62
|
| Rate for Payer: The Alliance Commercial |
$199.68
|
| Rate for Payer: WEA Trust Commercial |
$219.65
|
| Rate for Payer: WPS Commercial |
$295.80
|
|
|
BRACE ELBOW IROM LARGE LEFT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$324.69 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Aetna Managed Medicare |
$324.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$753.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$579.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$648.93
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$869.70
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: NAPHCARE Commercial |
$695.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$753.74
|
| Rate for Payer: Quartz Medicare Advantage |
$695.76
|
| Rate for Payer: The Alliance Commercial |
$579.80
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
BRACE ELBOW IROM LARGE LEFT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$568.20 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$695.76
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
BRACE ELBOW IROM LARGE RIGHT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$324.69 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Aetna Managed Medicare |
$324.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$753.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$579.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$648.93
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$869.70
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: NAPHCARE Commercial |
$695.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$753.74
|
| Rate for Payer: Quartz Medicare Advantage |
$695.76
|
| Rate for Payer: The Alliance Commercial |
$579.80
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
BRACE ELBOW IROM LARGE RIGHT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$568.20 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$695.76
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
