|
Acetylcholine Receptor Blocking Antibody
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 86042
|
| Hospital Charge Code |
5546927
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$158.08 |
| Rate for Payer: Aetna Commercial |
$158.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$158.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$151.42
|
| Rate for Payer: HFN Commercial |
$158.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$158.08
|
| Rate for Payer: Quartz Beloit One Network |
$73.22
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$158.08 |
| Rate for Payer: Aetna Commercial |
$158.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$158.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$151.42
|
| Rate for Payer: HFN Commercial |
$158.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$158.08
|
| Rate for Payer: Quartz Beloit One Network |
$73.22
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna Commercial |
$149.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.87
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$153.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$148.10
|
| Rate for Payer: HFN Commercial |
$153.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$153.09
|
| Rate for Payer: Quartz Beloit One Network |
$81.54
|
| Rate for Payer: Quartz Commercial |
$108.16
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$123.25
|
|
|
Acetylcholine Receptor Modulating Antibody
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
5546928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$81.54 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna Commercial |
$149.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.19
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$153.09
|
| Rate for Payer: Health EOS Commercial |
$148.10
|
| Rate for Payer: HFN Commercial |
$153.09
|
| Rate for Payer: Multiplan Commercial |
$133.12
|
| Rate for Payer: Preferred Network Access Commercial |
$153.09
|
| Rate for Payer: Quartz Beloit One Network |
$81.54
|
| Rate for Payer: Quartz Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$91.52
|
| Rate for Payer: WPS Commercial |
$123.25
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$33.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.06
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$71.76
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$71.76
|
| Rate for Payer: The Alliance Commercial |
$1.54
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
acetylcysteine for esophageal ablation [Med]
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2983114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Ace wrap applied, 3 in - Treatments Done
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
|
IP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$85.10 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$104.21
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Ace wrap applied, 3 in x2 - Treatments Done
|
Facility
|
OP
|
$167.00
|
|
| Hospital Charge Code |
3025941
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$48.63 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Aetna Managed Medicare |
$48.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$112.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.19
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.26
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: NAPHCARE Commercial |
$104.21
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$112.89
|
| Rate for Payer: Quartz Medicare Advantage |
$104.21
|
| Rate for Payer: The Alliance Commercial |
$86.84
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
|
IP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.42 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$157.25
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
Ace wrap applied, 3 in x3 - Treatments Done
|
Facility
|
OP
|
$252.00
|
|
| Hospital Charge Code |
3025940
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Aetna Managed Medicare |
$73.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$170.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.66
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.56
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: NAPHCARE Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$170.35
|
| Rate for Payer: Quartz Medicare Advantage |
$157.25
|
| Rate for Payer: The Alliance Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Ace wrap applied, 4 in - Treatments Done
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Ace wrap applied, 4 in x2 - Treatments Done
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
3025939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.39 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$122.93
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
Ace wrap applied, 4 in x2 - Treatments Done
|
Facility
|
OP
|
$197.00
|
|
| Hospital Charge Code |
3025939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$57.37 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$57.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.65
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.66
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$122.93
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$133.17
|
| Rate for Payer: Quartz Medicare Advantage |
$122.93
|
| Rate for Payer: The Alliance Commercial |
$102.44
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
Ace wrap applied, 4 in x3 - Treatments Done
|
Facility
|
OP
|
$294.00
|
|
| Hospital Charge Code |
3025938
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$85.61 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$275.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.95
|
| Rate for Payer: Aetna Managed Medicare |
$85.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$198.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$152.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$146.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.05
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$281.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.11
|
| Rate for Payer: Health EOS Commercial |
$272.13
|
| Rate for Payer: HFN Commercial |
$281.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$229.32
|
| Rate for Payer: Multiplan Commercial |
$244.61
|
| Rate for Payer: NAPHCARE Commercial |
$183.46
|
| Rate for Payer: Preferred Network Access Commercial |
$281.30
|
| Rate for Payer: Quartz Beloit One Network |
$149.82
|
| Rate for Payer: Quartz Commercial |
$198.74
|
| Rate for Payer: Quartz Medicare Advantage |
$183.46
|
| Rate for Payer: The Alliance Commercial |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$168.17
|
| Rate for Payer: WPS Commercial |
$226.47
|
|
|
Ace wrap applied, 4 in x3 - Treatments Done
|
Facility
|
IP
|
$294.00
|
|
| Hospital Charge Code |
3025938
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$149.82 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$275.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.05
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$281.30
|
| Rate for Payer: Health EOS Commercial |
$272.13
|
| Rate for Payer: HFN Commercial |
$281.30
|
| Rate for Payer: Multiplan Commercial |
$244.61
|
| Rate for Payer: Preferred Network Access Commercial |
$281.30
|
| Rate for Payer: Quartz Beloit One Network |
$149.82
|
| Rate for Payer: Quartz Commercial |
$183.46
|
| Rate for Payer: WEA Trust Commercial |
$168.17
|
| Rate for Payer: WPS Commercial |
$226.47
|
|
|
Ace wrap applied, 6 in - Treatments Done
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
3002564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
Ace wrap applied, 6 in - Treatments Done
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
3002564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
Ace wrap applied, 6 in x2 - Treatments Done
|
Facility
|
IP
|
$220.00
|
|
| Hospital Charge Code |
3025937
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$112.11 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$137.28
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
Ace wrap applied, 6 in x2 - Treatments Done
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
3025937
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.06 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$64.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.04
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.60
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$137.28
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$148.72
|
| Rate for Payer: Quartz Medicare Advantage |
$137.28
|
| Rate for Payer: The Alliance Commercial |
$114.40
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
Ace wrap applied, 6 in x3 - Treatments Done
|
Facility
|
IP
|
$343.00
|
|
| Hospital Charge Code |
3025936
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$174.79 |
| Max. Negotiated Rate |
$328.18 |
| Rate for Payer: Aetna Commercial |
$321.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.06
|
| Rate for Payer: Cash Price |
$102.90
|
| Rate for Payer: Cigna Commercial |
$328.18
|
| Rate for Payer: Health EOS Commercial |
$317.48
|
| Rate for Payer: HFN Commercial |
$328.18
|
| Rate for Payer: Multiplan Commercial |
$285.38
|
| Rate for Payer: Preferred Network Access Commercial |
$328.18
|
| Rate for Payer: Quartz Beloit One Network |
$174.79
|
| Rate for Payer: Quartz Commercial |
$214.03
|
| Rate for Payer: WEA Trust Commercial |
$196.20
|
| Rate for Payer: WPS Commercial |
$264.21
|
|
|
Ace wrap applied, 6 in x3 - Treatments Done
|
Facility
|
OP
|
$343.00
|
|
| Hospital Charge Code |
3025936
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$328.18 |
| Rate for Payer: Aetna Commercial |
$321.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.78
|
| Rate for Payer: Aetna Managed Medicare |
$99.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$231.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.06
|
| Rate for Payer: Cash Price |
$102.90
|
| Rate for Payer: Cigna Commercial |
$328.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.63
|
| Rate for Payer: Health EOS Commercial |
$317.48
|
| Rate for Payer: HFN Commercial |
$328.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.54
|
| Rate for Payer: Multiplan Commercial |
$285.38
|
| Rate for Payer: NAPHCARE Commercial |
$214.03
|
| Rate for Payer: Preferred Network Access Commercial |
$328.18
|
| Rate for Payer: Quartz Beloit One Network |
$174.79
|
| Rate for Payer: Quartz Commercial |
$231.87
|
| Rate for Payer: Quartz Medicare Advantage |
$214.03
|
| Rate for Payer: The Alliance Commercial |
$178.36
|
| Rate for Payer: WEA Trust Commercial |
$196.20
|
| Rate for Payer: WPS Commercial |
$264.21
|
|
|
ACHILLES TENDON REPAIR
|
Facility
|
IP
|
$4,492.00
|
|
| Hospital Charge Code |
2960411
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,289.12 |
| Max. Negotiated Rate |
$4,297.95 |
| Rate for Payer: Aetna Commercial |
$4,204.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,475.99
|
| Rate for Payer: Cash Price |
$1,347.60
|
| Rate for Payer: Cigna Commercial |
$4,297.95
|
| Rate for Payer: Health EOS Commercial |
$4,157.80
|
| Rate for Payer: HFN Commercial |
$4,297.95
|
| Rate for Payer: Multiplan Commercial |
$3,737.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,297.95
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.12
|
| Rate for Payer: Quartz Commercial |
$2,803.01
|
| Rate for Payer: WEA Trust Commercial |
$2,569.42
|
| Rate for Payer: WPS Commercial |
$3,460.19
|
|
