|
BRACE ELBOW IROM SMALL LEFT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2972033
|
|
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 SMALL LEFT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2972033
|
|
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 SMALL RIGHT
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
2964470
|
|
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 SMALL RIGHT
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
2964470
|
|
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 FOOTDROPS ADJUST
|
Facility
|
IP
|
$1,021.00
|
|
| Hospital Charge Code |
2971931
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$520.30 |
| Max. Negotiated Rate |
$976.89 |
| Rate for Payer: Aetna Commercial |
$955.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$913.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.78
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$976.89
|
| Rate for Payer: Health EOS Commercial |
$945.04
|
| Rate for Payer: HFN Commercial |
$976.89
|
| Rate for Payer: Multiplan Commercial |
$849.47
|
| Rate for Payer: Preferred Network Access Commercial |
$976.89
|
| Rate for Payer: Quartz Beloit One Network |
$520.30
|
| Rate for Payer: Quartz Commercial |
$637.10
|
| Rate for Payer: WEA Trust Commercial |
$584.01
|
| Rate for Payer: WPS Commercial |
$786.48
|
|
|
BRACE FOOTDROPS ADJUST
|
Facility
|
OP
|
$1,021.00
|
|
| Hospital Charge Code |
2971931
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$297.32 |
| Max. Negotiated Rate |
$976.89 |
| Rate for Payer: Aetna Commercial |
$955.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$913.18
|
| Rate for Payer: Aetna Managed Medicare |
$297.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$690.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$530.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$509.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$562.78
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cigna Commercial |
$976.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$594.22
|
| Rate for Payer: Health EOS Commercial |
$945.04
|
| Rate for Payer: HFN Commercial |
$976.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$796.38
|
| Rate for Payer: Multiplan Commercial |
$849.47
|
| Rate for Payer: NAPHCARE Commercial |
$637.10
|
| Rate for Payer: Preferred Network Access Commercial |
$976.89
|
| Rate for Payer: Quartz Beloit One Network |
$520.30
|
| Rate for Payer: Quartz Commercial |
$690.20
|
| Rate for Payer: Quartz Medicare Advantage |
$637.10
|
| Rate for Payer: The Alliance Commercial |
$530.92
|
| Rate for Payer: WEA Trust Commercial |
$584.01
|
| Rate for Payer: WPS Commercial |
$786.48
|
|
|
BRACE HUMERAL #L3980
|
Facility
|
OP
|
$3,719.00
|
|
| Hospital Charge Code |
2974045
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,082.97 |
| Max. Negotiated Rate |
$3,558.34 |
| Rate for Payer: Aetna Commercial |
$3,480.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,326.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,082.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,514.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,933.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,856.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,049.91
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,558.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,164.46
|
| Rate for Payer: Health EOS Commercial |
$3,442.31
|
| Rate for Payer: HFN Commercial |
$3,558.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,900.82
|
| Rate for Payer: Multiplan Commercial |
$3,094.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,320.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,558.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,895.20
|
| Rate for Payer: Quartz Commercial |
$2,514.04
|
| Rate for Payer: Quartz Medicare Advantage |
$2,320.66
|
| Rate for Payer: The Alliance Commercial |
$1,933.88
|
| Rate for Payer: WEA Trust Commercial |
$2,127.27
|
| Rate for Payer: WPS Commercial |
$2,864.75
|
|
|
BRACE HUMERAL #L3980
|
Facility
|
IP
|
$3,719.00
|
|
| Hospital Charge Code |
2974045
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,895.20 |
| Max. Negotiated Rate |
$3,558.34 |
| Rate for Payer: Aetna Commercial |
$3,480.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,326.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,049.91
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,558.34
|
| Rate for Payer: Health EOS Commercial |
$3,442.31
|
| Rate for Payer: HFN Commercial |
$3,558.34
|
| Rate for Payer: Multiplan Commercial |
$3,094.21
|
| Rate for Payer: Preferred Network Access Commercial |
$3,558.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,895.20
|
| Rate for Payer: Quartz Commercial |
$2,320.66
|
| Rate for Payer: WEA Trust Commercial |
$2,127.27
|
| Rate for Payer: WPS Commercial |
$2,864.75
|
|
|
BRACE KNEE LG 5674-BLK-L
|
Facility
|
IP
|
$1,025.00
|
|
| Hospital Charge Code |
3072450
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$522.34 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$639.60
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
BRACE KNEE LG 5674-BLK-L
|
Facility
|
OP
|
$1,025.00
|
|
| Hospital Charge Code |
3072450
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$298.48 |
| Max. Negotiated Rate |
$980.72 |
| Rate for Payer: Aetna Commercial |
$959.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$916.76
|
| Rate for Payer: Aetna Managed Medicare |
$298.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$692.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$533.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$511.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$564.98
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$980.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$596.55
|
| Rate for Payer: Health EOS Commercial |
$948.74
|
| Rate for Payer: HFN Commercial |
$980.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$799.50
|
| Rate for Payer: Multiplan Commercial |
$852.80
|
| Rate for Payer: NAPHCARE Commercial |
$639.60
|
| Rate for Payer: Preferred Network Access Commercial |
$980.72
|
| Rate for Payer: Quartz Beloit One Network |
$522.34
|
| Rate for Payer: Quartz Commercial |
$692.90
|
| Rate for Payer: Quartz Medicare Advantage |
$639.60
|
| Rate for Payer: The Alliance Commercial |
$533.00
|
| Rate for Payer: WEA Trust Commercial |
$586.30
|
| Rate for Payer: WPS Commercial |
$789.56
|
|
|
BRACE SUMIT L0456
|
Facility
|
OP
|
$4,951.00
|
|
| Hospital Charge Code |
2974112
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,441.73 |
| Max. Negotiated Rate |
$4,737.12 |
| Rate for Payer: Aetna Commercial |
$4,634.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,428.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,441.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,346.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,574.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,471.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,728.99
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,737.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,881.48
|
| Rate for Payer: Health EOS Commercial |
$4,582.65
|
| Rate for Payer: HFN Commercial |
$4,737.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,861.78
|
| Rate for Payer: Multiplan Commercial |
$4,119.23
|
| Rate for Payer: NAPHCARE Commercial |
$3,089.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.03
|
| Rate for Payer: Quartz Commercial |
$3,346.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,089.42
|
| Rate for Payer: The Alliance Commercial |
$2,574.52
|
| Rate for Payer: WEA Trust Commercial |
$2,831.97
|
| Rate for Payer: WPS Commercial |
$3,813.76
|
|
|
BRACE SUMIT L0456
|
Facility
|
IP
|
$4,951.00
|
|
| Hospital Charge Code |
2974112
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,523.03 |
| Max. Negotiated Rate |
$4,737.12 |
| Rate for Payer: Aetna Commercial |
$4,634.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,428.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,728.99
|
| Rate for Payer: Cash Price |
$1,485.30
|
| Rate for Payer: Cigna Commercial |
$4,737.12
|
| Rate for Payer: Health EOS Commercial |
$4,582.65
|
| Rate for Payer: HFN Commercial |
$4,737.12
|
| Rate for Payer: Multiplan Commercial |
$4,119.23
|
| Rate for Payer: Preferred Network Access Commercial |
$4,737.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,523.03
|
| Rate for Payer: Quartz Commercial |
$3,089.42
|
| Rate for Payer: WEA Trust Commercial |
$2,831.97
|
| Rate for Payer: WPS Commercial |
$3,813.76
|
|
|
BRACE THUMB SPICA MED/RIGHT #350MR
|
Facility
|
OP
|
$425.00
|
|
| Hospital Charge Code |
2969593
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Aetna Managed Medicare |
$123.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$287.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$221.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$212.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.35
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$331.50
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$287.30
|
| Rate for Payer: Quartz Medicare Advantage |
$265.20
|
| Rate for Payer: The Alliance Commercial |
$221.00
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
BRACE THUMB SPICA MED/RIGHT #350MR
|
Facility
|
IP
|
$425.00
|
|
| Hospital Charge Code |
2969593
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
BRACE THUMB SPICA SML RIGHT
|
Facility
|
OP
|
$425.00
|
|
| Hospital Charge Code |
2969592
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Aetna Managed Medicare |
$123.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$287.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$221.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$212.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.35
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$331.50
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$287.30
|
| Rate for Payer: Quartz Medicare Advantage |
$265.20
|
| Rate for Payer: The Alliance Commercial |
$221.00
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
BRACE THUMB SPICA SML RIGHT
|
Facility
|
IP
|
$425.00
|
|
| Hospital Charge Code |
2969592
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.38
|
|
|
BRACHIAL CLEFT CYST EXCISION
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
BRACHIAL CLEFT CYST EXCISION
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
BRACHIOPLASTY/BRACHIAL PLEXUS SURGERY
|
Facility
|
IP
|
$12,095.00
|
|
| Hospital Charge Code |
2959871
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,163.61 |
| Max. Negotiated Rate |
$11,572.50 |
| Rate for Payer: Aetna Commercial |
$11,320.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,817.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,666.76
|
| Rate for Payer: Cash Price |
$3,628.50
|
| Rate for Payer: Cigna Commercial |
$11,572.50
|
| Rate for Payer: Health EOS Commercial |
$11,195.13
|
| Rate for Payer: HFN Commercial |
$11,572.50
|
| Rate for Payer: Multiplan Commercial |
$10,063.04
|
| Rate for Payer: Preferred Network Access Commercial |
$11,572.50
|
| Rate for Payer: Quartz Beloit One Network |
$6,163.61
|
| Rate for Payer: Quartz Commercial |
$7,547.28
|
| Rate for Payer: WEA Trust Commercial |
$6,918.34
|
| Rate for Payer: WPS Commercial |
$9,316.78
|
|
|
BRACHIOPLASTY/BRACHIAL PLEXUS SURGERY
|
Facility
|
OP
|
$12,095.00
|
|
| Hospital Charge Code |
2959871
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,522.06 |
| Max. Negotiated Rate |
$11,572.50 |
| Rate for Payer: Aetna Commercial |
$11,320.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,817.77
|
| Rate for Payer: Aetna Managed Medicare |
$3,522.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,176.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,289.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,037.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,666.76
|
| Rate for Payer: Cash Price |
$3,628.50
|
| Rate for Payer: Cigna Commercial |
$11,572.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,039.29
|
| Rate for Payer: Health EOS Commercial |
$11,195.13
|
| Rate for Payer: HFN Commercial |
$11,572.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,434.10
|
| Rate for Payer: Multiplan Commercial |
$10,063.04
|
| Rate for Payer: NAPHCARE Commercial |
$7,547.28
|
| Rate for Payer: Preferred Network Access Commercial |
$11,572.50
|
| Rate for Payer: Quartz Beloit One Network |
$6,163.61
|
| Rate for Payer: Quartz Commercial |
$8,176.22
|
| Rate for Payer: Quartz Medicare Advantage |
$7,547.28
|
| Rate for Payer: The Alliance Commercial |
$6,289.40
|
| Rate for Payer: WEA Trust Commercial |
$6,918.34
|
| Rate for Payer: WPS Commercial |
$9,316.78
|
|
|
BRAF Mutation
|
Professional
|
Both
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$182.42 |
| Max. Negotiated Rate |
$827.94 |
| Rate for Payer: Aetna Commercial |
$827.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.51
|
| Rate for Payer: Aetna Managed Medicare |
$182.42
|
| Rate for Payer: Anthem Medicare Advantage |
$182.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$182.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$182.42
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$827.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$435.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.42
|
| Rate for Payer: Health EOS Commercial |
$793.08
|
| Rate for Payer: HFN Commercial |
$827.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$643.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$643.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$182.42
|
| Rate for Payer: Multiplan Commercial |
$697.22
|
| Rate for Payer: NAPHCARE Commercial |
$273.62
|
| Rate for Payer: Preferred Network Access Commercial |
$827.94
|
| Rate for Payer: Quartz Beloit One Network |
$383.47
|
| Rate for Payer: Quartz Commercial |
$496.77
|
| Rate for Payer: Quartz Medicare Advantage |
$182.42
|
| Rate for Payer: The Alliance Commercial |
$720.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.42
|
| Rate for Payer: WEA Trust Commercial |
$479.34
|
| Rate for Payer: WPS Commercial |
$802.63
|
|
|
BRAF Mutation
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$427.04 |
| Max. Negotiated Rate |
$801.80 |
| Rate for Payer: Aetna Commercial |
$784.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$461.91
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$801.80
|
| Rate for Payer: Health EOS Commercial |
$775.65
|
| Rate for Payer: HFN Commercial |
$801.80
|
| Rate for Payer: Multiplan Commercial |
$697.22
|
| Rate for Payer: Preferred Network Access Commercial |
$801.80
|
| Rate for Payer: Quartz Beloit One Network |
$427.04
|
| Rate for Payer: Quartz Commercial |
$522.91
|
| Rate for Payer: WEA Trust Commercial |
$479.34
|
| Rate for Payer: WPS Commercial |
$645.51
|
|
|
BRAF Mutation
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
CPT 81210
|
| Hospital Charge Code |
4634641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$182.42 |
| Max. Negotiated Rate |
$801.80 |
| Rate for Payer: Aetna Commercial |
$784.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$749.51
|
| Rate for Payer: Aetna Managed Medicare |
$182.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$684.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$319.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$302.81
|
| Rate for Payer: Anthem Medicare Advantage |
$182.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$461.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$182.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$182.42
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cash Price |
$251.40
|
| Rate for Payer: Cigna Commercial |
$801.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$182.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$487.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$182.42
|
| Rate for Payer: Health EOS Commercial |
$775.65
|
| Rate for Payer: HFN Commercial |
$801.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$678.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$182.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$182.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$182.42
|
| Rate for Payer: Multiplan Commercial |
$697.22
|
| Rate for Payer: NAPHCARE Commercial |
$273.62
|
| Rate for Payer: Preferred Network Access Commercial |
$801.80
|
| Rate for Payer: Quartz Beloit One Network |
$427.04
|
| Rate for Payer: Quartz Commercial |
$566.49
|
| Rate for Payer: Quartz Medicare Advantage |
$182.42
|
| Rate for Payer: The Alliance Commercial |
$729.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.42
|
| Rate for Payer: United Healthcare PPO |
$653.64
|
| Rate for Payer: WEA Trust Commercial |
$479.34
|
| Rate for Payer: Wellcare Medicare |
$182.42
|
| Rate for Payer: WPS Commercial |
$645.51
|
|
|
Brain cavity shunt w/scope 62201
|
Professional
|
Both
|
$6,406.00
|
|
|
Service Code
|
CPT 62201
|
| Hospital Charge Code |
6178531
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,096.89 |
| Max. Negotiated Rate |
$6,329.13 |
| Rate for Payer: Aetna Commercial |
$6,329.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,729.53
|
| Rate for Payer: Aetna Managed Medicare |
$1,096.89
|
| Rate for Payer: Anthem Medicare Advantage |
$1,096.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,096.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,096.89
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cash Price |
$1,921.80
|
| Rate for Payer: Cigna Commercial |
$6,329.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,137.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,096.89
|
| Rate for Payer: Health EOS Commercial |
$6,062.64
|
| Rate for Payer: HFN Commercial |
$6,329.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,949.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,949.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,096.89
|
| Rate for Payer: Multiplan Commercial |
$5,329.79
|
| Rate for Payer: NAPHCARE Commercial |
$1,645.33
|
| Rate for Payer: Preferred Network Access Commercial |
$6,329.13
|
| Rate for Payer: Quartz Beloit One Network |
$2,931.39
|
| Rate for Payer: Quartz Commercial |
$3,797.48
|
| Rate for Payer: Quartz Medicare Advantage |
$1,096.89
|
| Rate for Payer: The Alliance Commercial |
$4,661.77
|
| Rate for Payer: United Healthcare Medicaid |
$1,137.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,096.89
|
| Rate for Payer: WEA Trust Commercial |
$3,664.23
|
| Rate for Payer: WPS Commercial |
$4,936.00
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$8,680.63
|
|
|
Service Code
|
APR-DRG 0562
|
| Min. Negotiated Rate |
$7,710.67 |
| Max. Negotiated Rate |
$8,680.63 |
| Rate for Payer: Anthem Medicaid |
$8,312.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,312.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,312.18
|
| Rate for Payer: Dean Health Medicaid |
$8,312.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,710.67
|
| Rate for Payer: Managed Health Services Medicaid |
$8,680.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,312.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,312.18
|
| Rate for Payer: United Healthcare Medicaid |
$8,312.18
|
|
