|
BULKING AGENT COAPTITE 1CC M0068903000
|
Facility
|
OP
|
$4,336.00
|
|
|
Service Code
|
HCPCS L8606
|
| Hospital Charge Code |
5382978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.03 |
| Max. Negotiated Rate |
$17,344.00 |
| Rate for Payer: Aetna Commercial |
$3,902.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,728.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.08
|
| Rate for Payer: Cash Price |
$1,300.80
|
| Rate for Payer: Cash Price |
$1,300.80
|
| Rate for Payer: Cigna Commercial |
$3,989.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.43
|
| Rate for Payer: Health EOS Commercial |
$3,859.04
|
| Rate for Payer: HFN Commercial |
$3,989.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.00
|
| Rate for Payer: Multiplan Commercial |
$3,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,601.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.64
|
| Rate for Payer: Quartz Commercial |
$2,818.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,601.60
|
| Rate for Payer: The Alliance Commercial |
$17,344.00
|
| Rate for Payer: WEA Trust Commercial |
$2,384.80
|
| Rate for Payer: WPS Commercial |
$3,211.68
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Facility
|
OP
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$353.28 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.89
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$249.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$46.12
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Professional
|
Both
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.70 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$364.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$364.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.40
|
| Rate for Payer: Health EOS Commercial |
$349.44
|
| Rate for Payer: HFN Commercial |
$364.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: Preferred Network Access Commercial |
$364.80
|
| Rate for Payer: Quartz Beloit One Network |
$168.96
|
| Rate for Payer: Quartz Commercial |
$218.88
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Facility
|
IP
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$188.16 |
| Max. Negotiated Rate |
$353.28 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$230.40
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Bumetanide 0.5mg S0171
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Bumetanide 0.5mg S0171
|
Professional
|
Both
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.00
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Bumetanide 0.5mg S0171
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Bumetanide JW Waste Charge per 0.5mg
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS S0171 JW
|
| Hospital Charge Code |
5266710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Aetna Managed Medicare |
$2.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.60
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6.00
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Bumetanide JW Waste Charge per 0.5mg
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS S0171 JW
|
| Hospital Charge Code |
5266710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Aetna Commercial |
$9.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.00
|
| Rate for Payer: Health EOS Commercial |
$9.10
|
| Rate for Payer: HFN Commercial |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.50
|
| Rate for Payer: Quartz Beloit One Network |
$4.40
|
| Rate for Payer: Quartz Commercial |
$5.70
|
| Rate for Payer: The Alliance Commercial |
$5.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Bumetanide JW Waste Charge per 0.5mg
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS S0171 JW
|
| Hospital Charge Code |
5266710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
BUMPER FOAM
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2970612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
BUMPER FOAM
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
2970612
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
BUMPER PAD
|
Facility
|
OP
|
$3,697.00
|
|
| Hospital Charge Code |
3075867
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,035.16 |
| Max. Negotiated Rate |
$14,788.00 |
| Rate for Payer: Aetna Commercial |
$3,327.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,179.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,035.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,403.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,848.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,774.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,959.41
|
| Rate for Payer: Cash Price |
$1,109.10
|
| Rate for Payer: Cigna Commercial |
$3,401.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,068.84
|
| Rate for Payer: Health EOS Commercial |
$3,290.33
|
| Rate for Payer: HFN Commercial |
$3,401.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,772.75
|
| Rate for Payer: Multiplan Commercial |
$2,957.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,218.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,401.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,811.53
|
| Rate for Payer: Quartz Commercial |
$2,403.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,218.20
|
| Rate for Payer: The Alliance Commercial |
$14,788.00
|
| Rate for Payer: WEA Trust Commercial |
$2,033.35
|
| Rate for Payer: WPS Commercial |
$2,738.37
|
|
|
BUMPER PAD
|
Facility
|
IP
|
$3,697.00
|
|
| Hospital Charge Code |
3075867
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,811.53 |
| Max. Negotiated Rate |
$3,401.24 |
| Rate for Payer: Aetna Commercial |
$3,327.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,179.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,959.41
|
| Rate for Payer: Cash Price |
$1,109.10
|
| Rate for Payer: Cigna Commercial |
$3,401.24
|
| Rate for Payer: Health EOS Commercial |
$3,290.33
|
| Rate for Payer: HFN Commercial |
$3,401.24
|
| Rate for Payer: Multiplan Commercial |
$2,957.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,218.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,401.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,811.53
|
| Rate for Payer: Quartz Commercial |
$2,218.20
|
| Rate for Payer: WEA Trust Commercial |
$2,033.35
|
| Rate for Payer: WPS Commercial |
$2,738.37
|
|
|
Bumper Pad/Seizure Pads - Devices and Equipment
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
3716169
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Bumper Pad/Seizure Pads - Devices and Equipment
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
3716169
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
BUMP PACK MIS STERILE MICA 57S1MI08
|
Facility
|
IP
|
$5,660.00
|
|
| Hospital Charge Code |
6199056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,773.40 |
| Max. Negotiated Rate |
$5,207.20 |
| Rate for Payer: Aetna Commercial |
$5,094.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,867.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,999.80
|
| Rate for Payer: Cash Price |
$1,698.00
|
| Rate for Payer: Cigna Commercial |
$5,207.20
|
| Rate for Payer: Health EOS Commercial |
$5,037.40
|
| Rate for Payer: HFN Commercial |
$5,207.20
|
| Rate for Payer: Multiplan Commercial |
$4,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,207.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,773.40
|
| Rate for Payer: Quartz Commercial |
$3,396.00
|
| Rate for Payer: WEA Trust Commercial |
$3,113.00
|
| Rate for Payer: WPS Commercial |
$4,192.36
|
|
|
BUMP PACK MIS STERILE MICA 57S1MI08
|
Facility
|
OP
|
$5,660.00
|
|
| Hospital Charge Code |
6199056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,584.80 |
| Max. Negotiated Rate |
$22,640.00 |
| Rate for Payer: Aetna Commercial |
$5,094.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,867.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,584.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,679.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,830.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,716.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,999.80
|
| Rate for Payer: Cash Price |
$1,698.00
|
| Rate for Payer: Cigna Commercial |
$5,207.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,167.34
|
| Rate for Payer: Health EOS Commercial |
$5,037.40
|
| Rate for Payer: HFN Commercial |
$5,207.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,245.00
|
| Rate for Payer: Multiplan Commercial |
$4,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,207.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,773.40
|
| Rate for Payer: Quartz Commercial |
$3,679.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,396.00
|
| Rate for Payer: The Alliance Commercial |
$22,640.00
|
| Rate for Payer: WEA Trust Commercial |
$3,113.00
|
| Rate for Payer: WPS Commercial |
$4,192.36
|
|
|
BUNION AIDER 66451
|
Facility
|
OP
|
$427.00
|
|
| Hospital Charge Code |
3072621
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$1,708.00 |
| Rate for Payer: Aetna Commercial |
$384.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.22
|
| Rate for Payer: Aetna Managed Medicare |
$119.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$277.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$213.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.31
|
| Rate for Payer: Cash Price |
$128.10
|
| Rate for Payer: Cigna Commercial |
$392.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.95
|
| Rate for Payer: Health EOS Commercial |
$380.03
|
| Rate for Payer: HFN Commercial |
$392.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$320.25
|
| Rate for Payer: Multiplan Commercial |
$341.60
|
| Rate for Payer: NAPHCARE Commercial |
$256.20
|
| Rate for Payer: Preferred Network Access Commercial |
$392.84
|
| Rate for Payer: Quartz Beloit One Network |
$209.23
|
| Rate for Payer: Quartz Commercial |
$277.55
|
| Rate for Payer: Quartz Medicare Advantage |
$256.20
|
| Rate for Payer: The Alliance Commercial |
$1,708.00
|
| Rate for Payer: WEA Trust Commercial |
$234.85
|
| Rate for Payer: WPS Commercial |
$316.28
|
|
|
BUNION AIDER 66451
|
Facility
|
IP
|
$427.00
|
|
| Hospital Charge Code |
3072621
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$209.23 |
| Max. Negotiated Rate |
$392.84 |
| Rate for Payer: Aetna Commercial |
$384.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.31
|
| Rate for Payer: Cash Price |
$128.10
|
| Rate for Payer: Cigna Commercial |
$392.84
|
| Rate for Payer: Health EOS Commercial |
$380.03
|
| Rate for Payer: HFN Commercial |
$392.84
|
| Rate for Payer: Multiplan Commercial |
$341.60
|
| Rate for Payer: NAPHCARE Commercial |
$256.20
|
| Rate for Payer: Preferred Network Access Commercial |
$392.84
|
| Rate for Payer: Quartz Beloit One Network |
$209.23
|
| Rate for Payer: Quartz Commercial |
$256.20
|
| Rate for Payer: WEA Trust Commercial |
$234.85
|
| Rate for Payer: WPS Commercial |
$316.28
|
|
|
BUNIONECTOMY
|
Facility
|
IP
|
$1,757.00
|
|
| Hospital Charge Code |
2950492
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$860.93 |
| Max. Negotiated Rate |
$1,616.44 |
| Rate for Payer: Aetna Commercial |
$1,581.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,511.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$931.21
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,616.44
|
| Rate for Payer: Health EOS Commercial |
$1,563.73
|
| Rate for Payer: HFN Commercial |
$1,616.44
|
| Rate for Payer: Multiplan Commercial |
$1,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,616.44
|
| Rate for Payer: Quartz Beloit One Network |
$860.93
|
| Rate for Payer: Quartz Commercial |
$1,054.20
|
| Rate for Payer: WEA Trust Commercial |
$966.35
|
| Rate for Payer: WPS Commercial |
$1,301.41
|
|
|
BUNIONECTOMY
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2950492
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$491.96 |
| Max. Negotiated Rate |
$7,028.00 |
| Rate for Payer: Aetna Commercial |
$1,581.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,511.02
|
| Rate for Payer: Aetna Managed Medicare |
$491.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,142.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$878.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$843.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$931.21
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,616.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$983.22
|
| Rate for Payer: Health EOS Commercial |
$1,563.73
|
| Rate for Payer: HFN Commercial |
$1,616.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,317.75
|
| Rate for Payer: Multiplan Commercial |
$1,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,616.44
|
| Rate for Payer: Quartz Beloit One Network |
$860.93
|
| Rate for Payer: Quartz Commercial |
$1,142.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,054.20
|
| Rate for Payer: The Alliance Commercial |
$7,028.00
|
| Rate for Payer: WEA Trust Commercial |
$966.35
|
| Rate for Payer: WPS Commercial |
$1,301.41
|
|
|
BUNION SLING LFT LRG 66545/NA/NA/LL
|
Facility
|
IP
|
$360.00
|
|
| Hospital Charge Code |
3072624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
BUNION SLING LFT LRG 66545/NA/NA/LL
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
3072624
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$100.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$234.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$172.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.46
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.00
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: Quartz Medicare Advantage |
$216.00
|
| Rate for Payer: The Alliance Commercial |
$1,440.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
BUNION SLING LFT SM 66545/NA/NA/LS
|
Facility
|
IP
|
$360.00
|
|
| Hospital Charge Code |
3072625
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
