|
Acetic Acid 0.25% Irrigation 250ml [MED]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS A4321
|
| Hospital Charge Code |
2974895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
|
IP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$196.20
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Acetylcholine Ophth Solution 2ml [Med]
|
Facility
|
OP
|
$327.00
|
|
| Hospital Charge Code |
2974965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.56 |
| Max. Negotiated Rate |
$1,308.00 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Aetna Managed Medicare |
$91.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$212.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.99
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$245.25
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$212.55
|
| Rate for Payer: Quartz Medicare Advantage |
$196.20
|
| Rate for Payer: The Alliance Commercial |
$1,308.00
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Binding Antibody
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Binding Antibody
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 86041
|
| Hospital Charge Code |
2942963
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$39.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.20
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.34
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$91.00
|
| Rate for Payer: Quartz Medicare Advantage |
$84.00
|
| Rate for Payer: The Alliance Commercial |
$560.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: HFN Commercial |
$152.00
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.54
|
| Rate for Payer: Dean Health Medicaid |
$14.72
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.31
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.72
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.72
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$14.72
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Blocking Antibody
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: HFN Commercial |
$152.00
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$9.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.54
|
| Rate for Payer: Dean Health Medicaid |
$9.64
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.64
|
| Rate for Payer: Managed Health Services Medicaid |
$10.03
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.64
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$9.64
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$9.64
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.02
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$668.00 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.45
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.25
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$108.55
|
| Rate for Payer: Quartz Medicare Advantage |
$100.20
|
| Rate for Payer: The Alliance Commercial |
$668.00
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
|
OP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Aetna Managed Medicare |
$70.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$163.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.02
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$163.80
|
| Rate for Payer: Quartz Medicare Advantage |
$151.20
|
| Rate for Payer: The Alliance Commercial |
$1,008.00
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
|
IP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$123.48 |
| Max. Negotiated Rate |
$231.84 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$151.20
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Ace wrap applied, 4 in x2 - Treatments Done
|
Facility
|
OP
|
$197.00
|
|
| Hospital Charge Code |
3025939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$788.00 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Aetna Managed Medicare |
$55.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.75
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$128.05
|
| Rate for Payer: Quartz Medicare Advantage |
$118.20
|
| Rate for Payer: The Alliance Commercial |
$788.00
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Ace wrap applied, 4 in x2 - Treatments Done
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
3025939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$118.20
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Ace wrap applied, 4 in x3 - Treatments Done
|
Facility
|
OP
|
$294.00
|
|
| Hospital Charge Code |
3025938
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$82.32 |
| Max. Negotiated Rate |
$1,176.00 |
| Rate for Payer: Aetna Commercial |
$264.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$252.84
|
| Rate for Payer: Aetna Managed Medicare |
$82.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$191.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$147.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$141.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.82
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$270.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$164.52
|
| Rate for Payer: Health EOS Commercial |
$261.66
|
| Rate for Payer: HFN Commercial |
$270.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$220.50
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: NAPHCARE Commercial |
$176.40
|
| Rate for Payer: Preferred Network Access Commercial |
$270.48
|
| Rate for Payer: Quartz Beloit One Network |
$144.06
|
| Rate for Payer: Quartz Commercial |
$191.10
|
| Rate for Payer: Quartz Medicare Advantage |
$176.40
|
| Rate for Payer: The Alliance Commercial |
$1,176.00
|
| Rate for Payer: WEA Trust Commercial |
$161.70
|
| Rate for Payer: WPS Commercial |
$217.77
|
|
