|
Bright Tip 7Fr 90cm
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550946
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 45cm
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550948
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 45cm
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550948
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| 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: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 45cm
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550948
|
|
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
|
|
|
Bright Tip 8Fr 55cm
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550950
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| 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: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 55cm
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550950
|
|
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
|
|
|
Bright Tip 8Fr 55cm
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550950
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 90cm
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| 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: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 90cm
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
Bright Tip 8Fr 90cm
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550952
|
|
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
|
|
|
Brinzolamide 1% Ophth Suspension 5ml [Med]
|
Facility
|
IP
|
$841.00
|
|
| Hospital Charge Code |
2974910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$428.57 |
| Max. Negotiated Rate |
$804.67 |
| Rate for Payer: Aetna Commercial |
$787.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.56
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cigna Commercial |
$804.67
|
| Rate for Payer: Health EOS Commercial |
$778.43
|
| Rate for Payer: HFN Commercial |
$804.67
|
| Rate for Payer: Multiplan Commercial |
$699.71
|
| Rate for Payer: Preferred Network Access Commercial |
$804.67
|
| Rate for Payer: Quartz Beloit One Network |
$428.57
|
| Rate for Payer: Quartz Commercial |
$524.78
|
| Rate for Payer: WEA Trust Commercial |
$481.05
|
| Rate for Payer: WPS Commercial |
$647.82
|
|
|
Brinzolamide 1% Ophth Suspension 5ml [Med]
|
Facility
|
OP
|
$841.00
|
|
| Hospital Charge Code |
2974910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.90 |
| Max. Negotiated Rate |
$804.67 |
| Rate for Payer: Aetna Commercial |
$787.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.19
|
| Rate for Payer: Aetna Managed Medicare |
$244.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$568.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$437.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$419.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.56
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cigna Commercial |
$804.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$489.46
|
| Rate for Payer: Health EOS Commercial |
$778.43
|
| Rate for Payer: HFN Commercial |
$804.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$655.98
|
| Rate for Payer: Multiplan Commercial |
$699.71
|
| Rate for Payer: NAPHCARE Commercial |
$524.78
|
| Rate for Payer: Preferred Network Access Commercial |
$804.67
|
| Rate for Payer: Quartz Beloit One Network |
$428.57
|
| Rate for Payer: Quartz Commercial |
$568.52
|
| Rate for Payer: Quartz Medicare Advantage |
$524.78
|
| Rate for Payer: The Alliance Commercial |
$437.32
|
| Rate for Payer: WEA Trust Commercial |
$481.05
|
| Rate for Payer: WPS Commercial |
$647.82
|
|
|
Brivaracetam Level
|
Facility
|
OP
|
$552.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
5613548
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$160.74 |
| Max. Negotiated Rate |
$528.15 |
| Rate for Payer: Aetna Commercial |
$516.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.71
|
| Rate for Payer: Aetna Managed Medicare |
$160.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$275.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.26
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$528.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.26
|
| Rate for Payer: Health EOS Commercial |
$510.93
|
| Rate for Payer: HFN Commercial |
$528.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$430.56
|
| Rate for Payer: Multiplan Commercial |
$459.26
|
| Rate for Payer: NAPHCARE Commercial |
$344.45
|
| Rate for Payer: Preferred Network Access Commercial |
$528.15
|
| Rate for Payer: Quartz Beloit One Network |
$281.30
|
| Rate for Payer: Quartz Commercial |
$373.15
|
| Rate for Payer: Quartz Medicare Advantage |
$344.45
|
| Rate for Payer: The Alliance Commercial |
$287.04
|
| Rate for Payer: United Healthcare PPO |
$430.56
|
| Rate for Payer: WEA Trust Commercial |
$315.74
|
| Rate for Payer: WPS Commercial |
$425.21
|
|
|
Brivaracetam Level
|
Facility
|
IP
|
$552.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
5613548
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$281.30 |
| Max. Negotiated Rate |
$528.15 |
| Rate for Payer: Aetna Commercial |
$516.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.26
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$528.15
|
| Rate for Payer: Health EOS Commercial |
$510.93
|
| Rate for Payer: HFN Commercial |
$528.15
|
| Rate for Payer: Multiplan Commercial |
$459.26
|
| Rate for Payer: Preferred Network Access Commercial |
$528.15
|
| Rate for Payer: Quartz Beloit One Network |
$281.30
|
| Rate for Payer: Quartz Commercial |
$344.45
|
| Rate for Payer: WEA Trust Commercial |
$315.74
|
| Rate for Payer: WPS Commercial |
$425.21
|
|
|
Brivaracetam Level
|
Professional
|
Both
|
$552.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
5613548
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$545.38 |
| Rate for Payer: Aetna Commercial |
$545.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.71
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$545.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$287.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$344.45
|
| Rate for Payer: Health EOS Commercial |
$522.41
|
| Rate for Payer: HFN Commercial |
$545.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$459.26
|
| Rate for Payer: Preferred Network Access Commercial |
$545.38
|
| Rate for Payer: Quartz Beloit One Network |
$252.60
|
| Rate for Payer: Quartz Commercial |
$327.23
|
| Rate for Payer: The Alliance Commercial |
$287.04
|
| Rate for Payer: WEA Trust Commercial |
$315.74
|
| Rate for Payer: WPS Commercial |
$425.21
|
|
|
BROACH M.I.B. 317-00-006
|
Facility
|
OP
|
$2,516.00
|
|
| Hospital Charge Code |
5506862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$732.66 |
| Max. Negotiated Rate |
$2,407.31 |
| Rate for Payer: Aetna Commercial |
$2,354.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,250.31
|
| Rate for Payer: Aetna Managed Medicare |
$732.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,700.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,308.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,255.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,386.82
|
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cigna Commercial |
$2,407.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,464.31
|
| Rate for Payer: Health EOS Commercial |
$2,328.81
|
| Rate for Payer: HFN Commercial |
$2,407.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,962.48
|
| Rate for Payer: Multiplan Commercial |
$2,093.31
|
| Rate for Payer: NAPHCARE Commercial |
$1,569.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,407.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.15
|
| Rate for Payer: Quartz Commercial |
$1,700.82
|
| Rate for Payer: Quartz Medicare Advantage |
$1,569.98
|
| Rate for Payer: The Alliance Commercial |
$1,308.32
|
| Rate for Payer: WEA Trust Commercial |
$1,439.15
|
| Rate for Payer: WPS Commercial |
$1,938.07
|
|
|
BROACH M.I.B. 317-00-006
|
Facility
|
IP
|
$2,516.00
|
|
| Hospital Charge Code |
5506862
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,282.15 |
| Max. Negotiated Rate |
$2,407.31 |
| Rate for Payer: Aetna Commercial |
$2,354.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,250.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,386.82
|
| Rate for Payer: Cash Price |
$754.80
|
| Rate for Payer: Cigna Commercial |
$2,407.31
|
| Rate for Payer: Health EOS Commercial |
$2,328.81
|
| Rate for Payer: HFN Commercial |
$2,407.31
|
| Rate for Payer: Multiplan Commercial |
$2,093.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,407.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.15
|
| Rate for Payer: Quartz Commercial |
$1,569.98
|
| Rate for Payer: WEA Trust Commercial |
$1,439.15
|
| Rate for Payer: WPS Commercial |
$1,938.07
|
|
|
Bronchial Dble-Lumen Tubes
|
Facility
|
IP
|
$1,512.00
|
|
| Hospital Charge Code |
3101741
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$770.52 |
| Max. Negotiated Rate |
$1,446.68 |
| Rate for Payer: Aetna Commercial |
$1,415.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,352.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$833.41
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cigna Commercial |
$1,446.68
|
| Rate for Payer: Health EOS Commercial |
$1,399.51
|
| Rate for Payer: HFN Commercial |
$1,446.68
|
| Rate for Payer: Multiplan Commercial |
$1,257.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,446.68
|
| Rate for Payer: Quartz Beloit One Network |
$770.52
|
| Rate for Payer: Quartz Commercial |
$943.49
|
| Rate for Payer: WEA Trust Commercial |
$864.86
|
| Rate for Payer: WPS Commercial |
$1,164.69
|
|
|
Bronchial Dble-Lumen Tubes
|
Facility
|
OP
|
$1,512.00
|
|
| Hospital Charge Code |
3101741
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$440.29 |
| Max. Negotiated Rate |
$1,446.68 |
| Rate for Payer: Aetna Commercial |
$1,415.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,352.33
|
| Rate for Payer: Aetna Managed Medicare |
$440.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,022.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$786.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$754.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$833.41
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cigna Commercial |
$1,446.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$879.98
|
| Rate for Payer: Health EOS Commercial |
$1,399.51
|
| Rate for Payer: HFN Commercial |
$1,446.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,179.36
|
| Rate for Payer: Multiplan Commercial |
$1,257.98
|
| Rate for Payer: NAPHCARE Commercial |
$943.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,446.68
|
| Rate for Payer: Quartz Beloit One Network |
$770.52
|
| Rate for Payer: Quartz Commercial |
$1,022.11
|
| Rate for Payer: Quartz Medicare Advantage |
$943.49
|
| Rate for Payer: The Alliance Commercial |
$786.24
|
| Rate for Payer: WEA Trust Commercial |
$864.86
|
| Rate for Payer: WPS Commercial |
$1,164.69
|
|
|
Bronchial Provocation Test - Pulmonary Function Test Charge
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT 94070
|
| Hospital Charge Code |
3006999
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$458.64 |
| Max. Negotiated Rate |
$861.12 |
| Rate for Payer: Aetna Commercial |
$842.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$496.08
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$861.12
|
| Rate for Payer: Health EOS Commercial |
$833.04
|
| Rate for Payer: HFN Commercial |
$861.12
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: Preferred Network Access Commercial |
$861.12
|
| Rate for Payer: Quartz Beloit One Network |
$458.64
|
| Rate for Payer: Quartz Commercial |
$561.60
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: WPS Commercial |
$693.27
|
|
|
Bronchial Provocation Test - Pulmonary Function Test Charge
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT 94070
|
| Hospital Charge Code |
3006999
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$392.70 |
| Max. Negotiated Rate |
$1,570.82 |
| Rate for Payer: Aetna Commercial |
$842.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Aetna Managed Medicare |
$392.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$608.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$468.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$449.28
|
| Rate for Payer: Anthem Medicare Advantage |
$392.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$496.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$392.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$392.70
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$861.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$392.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$523.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$392.70
|
| Rate for Payer: Health EOS Commercial |
$833.04
|
| Rate for Payer: HFN Commercial |
$861.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,460.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$392.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$392.70
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$392.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$392.70
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: NAPHCARE Commercial |
$589.06
|
| Rate for Payer: Preferred Network Access Commercial |
$861.12
|
| Rate for Payer: Quartz Beloit One Network |
$458.64
|
| Rate for Payer: Quartz Commercial |
$608.40
|
| Rate for Payer: Quartz Medicare Advantage |
$392.70
|
| Rate for Payer: The Alliance Commercial |
$1,570.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$392.70
|
| Rate for Payer: United Healthcare PPO |
$702.00
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: Wellcare Medicare |
$392.70
|
| Rate for Payer: WPS Commercial |
$693.27
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$4,822.57
|
|
|
Service Code
|
APR-DRG 1382
|
| Min. Negotiated Rate |
$4,283.71 |
| Max. Negotiated Rate |
$4,822.57 |
| Rate for Payer: Anthem Medicaid |
$4,617.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,617.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,617.88
|
| Rate for Payer: Dean Health Medicaid |
$4,617.88
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,283.71
|
| Rate for Payer: Managed Health Services Medicaid |
$4,822.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,617.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,617.88
|
| Rate for Payer: United Healthcare Medicaid |
$4,617.88
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$16,484.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Min. Negotiated Rate |
$14,642.49 |
| Max. Negotiated Rate |
$16,484.42 |
| Rate for Payer: Anthem Medicaid |
$15,784.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$15,784.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15,784.74
|
| Rate for Payer: Dean Health Medicaid |
$15,784.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14,642.49
|
| Rate for Payer: Managed Health Services Medicaid |
$16,484.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,784.74
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15,784.74
|
| Rate for Payer: United Healthcare Medicaid |
$15,784.74
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$8,417.58
|
|
|
Service Code
|
APR-DRG 1383
|
| Min. Negotiated Rate |
$7,477.02 |
| Max. Negotiated Rate |
$8,417.58 |
| Rate for Payer: Anthem Medicaid |
$8,060.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,060.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,060.29
|
| Rate for Payer: Dean Health Medicaid |
$8,060.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,477.02
|
| Rate for Payer: Managed Health Services Medicaid |
$8,417.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,060.29
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,060.29
|
| Rate for Payer: United Healthcare Medicaid |
$8,060.29
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
OP
|
$81.24
|
|
|
Service Code
|
EAPG 00572
|
| Min. Negotiated Rate |
$78.11 |
| Max. Negotiated Rate |
$81.24 |
| Rate for Payer: Anthem Medicaid |
$78.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$78.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.11
|
| Rate for Payer: Dean Health Medicaid |
$78.11
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$78.11
|
| Rate for Payer: Managed Health Services Medicaid |
$81.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$78.11
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$78.11
|
| Rate for Payer: United Healthcare Medicaid |
$78.11
|
|
