|
BREAST IMPLANT REMOVAL
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959881
|
|
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
|
|
|
BREAST IMPLANT REMOVAL
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959881
|
|
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
|
|
|
Breast Needle Loc Wire
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5804377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
Breast Needle Loc Wire
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5804377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$48.05 |
| Max. Negotiated Rate |
$103.74 |
| Rate for Payer: Aetna Commercial |
$103.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.52
|
| Rate for Payer: Health EOS Commercial |
$99.37
|
| Rate for Payer: HFN Commercial |
$103.74
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$103.74
|
| Rate for Payer: Quartz Beloit One Network |
$48.05
|
| Rate for Payer: Quartz Commercial |
$62.24
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
Breast Needle Loc Wire
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5804377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$313.04 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$11,749.54
|
|
|
Service Code
|
APR-DRG 3631
|
| Min. Negotiated Rate |
$10,436.67 |
| Max. Negotiated Rate |
$11,749.54 |
| Rate for Payer: Anthem Medicaid |
$11,250.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11,250.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11,250.83
|
| Rate for Payer: Dean Health Medicaid |
$11,250.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,436.67
|
| Rate for Payer: Managed Health Services Medicaid |
$11,749.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,250.83
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11,250.83
|
| Rate for Payer: United Healthcare Medicaid |
$11,250.83
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$25,603.47
|
|
|
Service Code
|
APR-DRG 3633
|
| Min. Negotiated Rate |
$22,742.60 |
| Max. Negotiated Rate |
$25,603.47 |
| Rate for Payer: Anthem Medicaid |
$24,516.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$24,516.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24,516.73
|
| Rate for Payer: Dean Health Medicaid |
$24,516.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22,742.60
|
| Rate for Payer: Managed Health Services Medicaid |
$25,603.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,516.73
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24,516.73
|
| Rate for Payer: United Healthcare Medicaid |
$24,516.73
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$18,764.18
|
|
|
Service Code
|
APR-DRG 3632
|
| Min. Negotiated Rate |
$16,667.52 |
| Max. Negotiated Rate |
$18,764.18 |
| Rate for Payer: Anthem Medicaid |
$17,967.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$17,967.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17,967.74
|
| Rate for Payer: Dean Health Medicaid |
$17,967.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16,667.52
|
| Rate for Payer: Managed Health Services Medicaid |
$18,764.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,967.74
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17,967.74
|
| Rate for Payer: United Healthcare Medicaid |
$17,967.74
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$27,795.54
|
|
|
Service Code
|
APR-DRG 3634
|
| Min. Negotiated Rate |
$24,689.74 |
| Max. Negotiated Rate |
$27,795.54 |
| Rate for Payer: Anthem Medicaid |
$26,615.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26,615.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26,615.76
|
| Rate for Payer: Dean Health Medicaid |
$26,615.76
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24,689.74
|
| Rate for Payer: Managed Health Services Medicaid |
$27,795.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,615.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26,615.76
|
| Rate for Payer: United Healthcare Medicaid |
$26,615.76
|
|
|
Breast pump accessory kit - Devices and Equipment
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5551757
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.95
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Breast pump accessory kit - Devices and Equipment
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5551757
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
BREAST PUMP SYMPHONY HARMONY DOUBLE DUET KIT 67355S
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5496835
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$33.49 |
| Rate for Payer: Aetna Commercial |
$32.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.30
|
| Rate for Payer: Aetna Managed Medicare |
$10.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.29
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$33.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.37
|
| Rate for Payer: Health EOS Commercial |
$32.40
|
| Rate for Payer: HFN Commercial |
$33.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.30
|
| Rate for Payer: Multiplan Commercial |
$29.12
|
| Rate for Payer: NAPHCARE Commercial |
$21.84
|
| Rate for Payer: Preferred Network Access Commercial |
$33.49
|
| Rate for Payer: Quartz Beloit One Network |
$17.84
|
| Rate for Payer: Quartz Commercial |
$23.66
|
| Rate for Payer: Quartz Medicare Advantage |
$21.84
|
| Rate for Payer: The Alliance Commercial |
$18.20
|
| Rate for Payer: WEA Trust Commercial |
$20.02
|
| Rate for Payer: WPS Commercial |
$26.96
|
|
|
BREAST PUMP SYMPHONY HARMONY DOUBLE DUET KIT 67355S
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5496835
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.84 |
| Max. Negotiated Rate |
$33.49 |
| Rate for Payer: Aetna Commercial |
$32.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.29
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$33.49
|
| Rate for Payer: Health EOS Commercial |
$32.40
|
| Rate for Payer: HFN Commercial |
$33.49
|
| Rate for Payer: Multiplan Commercial |
$29.12
|
| Rate for Payer: Preferred Network Access Commercial |
$33.49
|
| Rate for Payer: Quartz Beloit One Network |
$17.84
|
| Rate for Payer: Quartz Commercial |
$21.84
|
| Rate for Payer: WEA Trust Commercial |
$20.02
|
| Rate for Payer: WPS Commercial |
$26.96
|
|
|
BREAST RECONSTRUCTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
BREAST RECONSTRUCTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
BREAST REDUCTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
Breathing Capacity Test 94010
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
3697554
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$121.52 |
| Rate for Payer: Aetna Commercial |
$121.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Medicare Advantage |
$29.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.41
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$121.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.41
|
| Rate for Payer: Health EOS Commercial |
$116.41
|
| Rate for Payer: HFN Commercial |
$121.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$103.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.41
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$44.12
|
| Rate for Payer: Preferred Network Access Commercial |
$121.52
|
| Rate for Payer: Quartz Beloit One Network |
$56.28
|
| Rate for Payer: Quartz Commercial |
$72.91
|
| Rate for Payer: Quartz Medicare Advantage |
$29.41
|
| Rate for Payer: The Alliance Commercial |
$73.53
|
| Rate for Payer: United Healthcare Medicaid |
$43.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.41
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$117.64
|
|
|
Breathing Capacity Test 9401026
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
CPT 94010 26
|
| Hospital Charge Code |
3149504
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$121.52 |
| Rate for Payer: Aetna Commercial |
$121.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$8.34
|
| Rate for Payer: Anthem Medicare Advantage |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.34
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$121.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.34
|
| Rate for Payer: Health EOS Commercial |
$116.41
|
| Rate for Payer: HFN Commercial |
$121.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.34
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$12.51
|
| Rate for Payer: Preferred Network Access Commercial |
$121.52
|
| Rate for Payer: Quartz Beloit One Network |
$56.28
|
| Rate for Payer: Quartz Commercial |
$72.91
|
| Rate for Payer: Quartz Medicare Advantage |
$8.34
|
| Rate for Payer: The Alliance Commercial |
$20.85
|
| Rate for Payer: United Healthcare Medicaid |
$14.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.34
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$33.36
|
|
|
Breathing Circuit
|
Facility
|
OP
|
$224.00
|
|
| Hospital Charge Code |
3101731
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Aetna Managed Medicare |
$65.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$151.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$116.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.37
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.72
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: NAPHCARE Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$151.42
|
| Rate for Payer: Quartz Medicare Advantage |
$139.78
|
| Rate for Payer: The Alliance Commercial |
$116.48
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
Breathing Circuit
|
Facility
|
IP
|
$224.00
|
|
| Hospital Charge Code |
3101731
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$114.15 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$139.78
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
BREEZE INFLATION SYSTEM M00566670
|
Facility
|
IP
|
$1,299.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$661.97 |
| Max. Negotiated Rate |
$1,242.88 |
| Rate for Payer: Aetna Commercial |
$1,215.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$716.01
|
| Rate for Payer: Cash Price |
$389.70
|
| Rate for Payer: Cigna Commercial |
$1,242.88
|
| Rate for Payer: Health EOS Commercial |
$1,202.35
|
| Rate for Payer: HFN Commercial |
$1,242.88
|
| Rate for Payer: Multiplan Commercial |
$1,080.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.88
|
| Rate for Payer: Quartz Beloit One Network |
$661.97
|
| Rate for Payer: Quartz Commercial |
$810.58
|
| Rate for Payer: WEA Trust Commercial |
$743.03
|
| Rate for Payer: WPS Commercial |
$1,000.62
|
|
|
BREEZE INFLATION SYSTEM M00566670
|
Facility
|
OP
|
$1,299.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2972170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$378.27 |
| Max. Negotiated Rate |
$1,242.88 |
| Rate for Payer: Aetna Commercial |
$1,215.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.83
|
| Rate for Payer: Aetna Managed Medicare |
$378.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$878.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$675.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$648.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$716.01
|
| Rate for Payer: Cash Price |
$389.70
|
| Rate for Payer: Cigna Commercial |
$1,242.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$756.02
|
| Rate for Payer: Health EOS Commercial |
$1,202.35
|
| Rate for Payer: HFN Commercial |
$1,242.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,013.22
|
| Rate for Payer: Multiplan Commercial |
$1,080.77
|
| Rate for Payer: NAPHCARE Commercial |
$810.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.88
|
| Rate for Payer: Quartz Beloit One Network |
$661.97
|
| Rate for Payer: Quartz Commercial |
$878.12
|
| Rate for Payer: Quartz Medicare Advantage |
$810.58
|
| Rate for Payer: The Alliance Commercial |
$675.48
|
| Rate for Payer: WEA Trust Commercial |
$743.03
|
| Rate for Payer: WPS Commercial |
$1,000.62
|
|
|
Brief Emotional/Behavioral Assessment 96127
|
Professional
|
Both
|
$47.00
|
|
|
Service Code
|
CPT 96127
|
| Hospital Charge Code |
5540690
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$46.44 |
| Rate for Payer: Aetna Commercial |
$46.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.04
|
| Rate for Payer: Aetna Managed Medicare |
$4.76
|
| Rate for Payer: Anthem Medicare Advantage |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.76
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$46.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.76
|
| Rate for Payer: Health EOS Commercial |
$44.48
|
| Rate for Payer: HFN Commercial |
$46.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.76
|
| Rate for Payer: Multiplan Commercial |
$39.10
|
| Rate for Payer: NAPHCARE Commercial |
$7.14
|
| Rate for Payer: Preferred Network Access Commercial |
$46.44
|
| Rate for Payer: Quartz Beloit One Network |
$21.51
|
| Rate for Payer: Quartz Commercial |
$27.86
|
| Rate for Payer: Quartz Medicare Advantage |
$4.76
|
| Rate for Payer: The Alliance Commercial |
$11.91
|
| Rate for Payer: United Healthcare Medicaid |
$4.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.76
|
| Rate for Payer: WEA Trust Commercial |
$26.88
|
| Rate for Payer: WPS Commercial |
$19.05
|
|
|
Bright Tip 5Fr 45cm
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550922
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
