|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$6,313.18
|
|
|
Service Code
|
APR-DRG 0561
|
| Min. Negotiated Rate |
$5,607.76 |
| Max. Negotiated Rate |
$6,313.18 |
| Rate for Payer: Anthem Medicaid |
$6,045.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,045.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,045.22
|
| Rate for Payer: Dean Health Medicaid |
$6,045.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,607.76
|
| Rate for Payer: Managed Health Services Medicaid |
$6,313.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,045.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,045.22
|
| Rate for Payer: United Healthcare Medicaid |
$6,045.22
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$23,674.44
|
|
|
Service Code
|
APR-DRG 0564
|
| Min. Negotiated Rate |
$21,029.11 |
| Max. Negotiated Rate |
$23,674.44 |
| Rate for Payer: Anthem Medicaid |
$22,669.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$22,669.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22,669.58
|
| Rate for Payer: Dean Health Medicaid |
$22,669.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,029.11
|
| Rate for Payer: Managed Health Services Medicaid |
$23,674.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,669.58
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22,669.58
|
| Rate for Payer: United Healthcare Medicaid |
$22,669.58
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$13,240.15
|
|
|
Service Code
|
APR-DRG 0563
|
| Min. Negotiated Rate |
$11,760.73 |
| Max. Negotiated Rate |
$13,240.15 |
| Rate for Payer: Anthem Medicaid |
$12,678.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,678.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,678.17
|
| Rate for Payer: Dean Health Medicaid |
$12,678.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,760.73
|
| Rate for Payer: Managed Health Services Medicaid |
$13,240.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,678.17
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,678.17
|
| Rate for Payer: United Healthcare Medicaid |
$12,678.17
|
|
|
BRA JODEE - 2 X LG
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971181
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.83 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Aetna Managed Medicare |
$134.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.47
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.14
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$312.99
|
| Rate for Payer: Quartz Medicare Advantage |
$288.91
|
| Rate for Payer: The Alliance Commercial |
$240.76
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE - 2 X LG
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971181
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.94 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$288.91
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE EXTRA LARGE
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971180
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.94 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$288.91
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE EXTRA LARGE
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971180
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.83 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Aetna Managed Medicare |
$134.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.47
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.14
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$312.99
|
| Rate for Payer: Quartz Medicare Advantage |
$288.91
|
| Rate for Payer: The Alliance Commercial |
$240.76
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE LARGE
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971179
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.83 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Aetna Managed Medicare |
$134.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.47
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.14
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$312.99
|
| Rate for Payer: Quartz Medicare Advantage |
$288.91
|
| Rate for Payer: The Alliance Commercial |
$240.76
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE LARGE
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971179
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.94 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$288.91
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE MEDIUM
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971178
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.94 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$288.91
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE MEDIUM
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971178
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.83 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Aetna Managed Medicare |
$134.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.47
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.14
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$312.99
|
| Rate for Payer: Quartz Medicare Advantage |
$288.91
|
| Rate for Payer: The Alliance Commercial |
$240.76
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE SMALL
|
Facility
|
IP
|
$463.00
|
|
| Hospital Charge Code |
2971177
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.94 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$288.91
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA JODEE SMALL
|
Facility
|
OP
|
$463.00
|
|
| Hospital Charge Code |
2971177
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.83 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$433.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.11
|
| Rate for Payer: Aetna Managed Medicare |
$134.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.21
|
| Rate for Payer: Cash Price |
$138.90
|
| Rate for Payer: Cigna Commercial |
$443.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.47
|
| Rate for Payer: Health EOS Commercial |
$428.55
|
| Rate for Payer: HFN Commercial |
$443.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.14
|
| Rate for Payer: Multiplan Commercial |
$385.22
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$443.00
|
| Rate for Payer: Quartz Beloit One Network |
$235.94
|
| Rate for Payer: Quartz Commercial |
$312.99
|
| Rate for Payer: Quartz Medicare Advantage |
$288.91
|
| Rate for Payer: The Alliance Commercial |
$240.76
|
| Rate for Payer: WEA Trust Commercial |
$264.84
|
| Rate for Payer: WPS Commercial |
$356.65
|
|
|
BRA MASETECTOMY KIT MEDEBRA 4X 52-54 IN A-C (MULTI-GENDER) MEDEKIT-007W
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$161.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.59
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$433.68
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$346.94
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$375.86
|
| Rate for Payer: Quartz Medicare Advantage |
$346.94
|
| Rate for Payer: The Alliance Commercial |
$307.05
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
BRA MASETECTOMY KIT MEDEBRA 4X 52-54 IN A-C (MULTI-GENDER) MEDEKIT-007W
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$283.34 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$346.94
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
BRA MASTECTOMY KIT MEDEBRA 1X 40-42 IN B-D MEDEKIT-004W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Aetna Managed Medicare |
$156.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.53
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.86
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: NAPHCARE Commercial |
$335.09
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$363.01
|
| Rate for Payer: Quartz Medicare Advantage |
$335.09
|
| Rate for Payer: The Alliance Commercial |
$216.86
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA 1X 40-42 IN B-D MEDEKIT-004W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.66 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$335.09
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA 2X 42-44 IN C-E MEDEKIT-005W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Aetna Managed Medicare |
$156.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.53
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.86
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: NAPHCARE Commercial |
$335.09
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$363.01
|
| Rate for Payer: Quartz Medicare Advantage |
$335.09
|
| Rate for Payer: The Alliance Commercial |
$307.05
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA 2X 42-44 IN C-E MEDEKIT-005W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.66 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$335.09
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA 3X 46-48 IN E-I MEDEKIT-006W
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611559
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$161.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.59
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$433.68
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$346.94
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$375.86
|
| Rate for Payer: Quartz Medicare Advantage |
$346.94
|
| Rate for Payer: The Alliance Commercial |
$216.86
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
BRA MASTECTOMY KIT MEDEBRA 3X 46-48 IN E-I MEDEKIT-006W
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
5611559
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$283.34 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$346.94
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
BRA MASTECTOMY KIT MEDEBRA LARGE 38-40 IN B-D MEDEKIT-003W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611556
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Aetna Managed Medicare |
$156.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.53
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.86
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: NAPHCARE Commercial |
$335.09
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$363.01
|
| Rate for Payer: Quartz Medicare Advantage |
$335.09
|
| Rate for Payer: The Alliance Commercial |
$307.05
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA LARGE 38-40 IN B-D MEDEKIT-003W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611556
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$273.66 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$335.09
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA MED 34-36 IN B-D MEDEKIT-002W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611555
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Aetna Managed Medicare |
$156.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.53
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.86
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: NAPHCARE Commercial |
$335.09
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$363.01
|
| Rate for Payer: Quartz Medicare Advantage |
$335.09
|
| Rate for Payer: The Alliance Commercial |
$307.05
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA MED 34-36 IN B-D MEDEKIT-002W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611555
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.66 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$335.09
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
