|
COMPONENT FEM G-MINUS RT GSF FLEX CR 00-5750-017-06
|
Facility
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM G-RT FLEX CR PRECOAT 5950-17-02
|
Facility
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,208.00 |
| Max. Negotiated Rate |
$17,112.00 |
| Rate for Payer: Aetna Commercial |
$16,740.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,996.00
|
| Rate for Payer: Aetna Managed Medicare |
$5,208.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,090.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,300.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,928.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,858.00
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,112.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,408.56
|
| Rate for Payer: Health EOS Commercial |
$16,554.00
|
| Rate for Payer: HFN Commercial |
$17,112.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,950.00
|
| Rate for Payer: Multiplan Commercial |
$14,880.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,160.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,112.00
|
| Rate for Payer: Quartz Beloit One Network |
$9,114.00
|
| Rate for Payer: Quartz Commercial |
$12,090.00
|
| Rate for Payer: Quartz Medicare Advantage |
$11,160.00
|
| Rate for Payer: WEA Trust Commercial |
$10,230.00
|
| Rate for Payer: WPS Commercial |
$13,777.02
|
|
|
COMPONENT FEM G-RT FLEX CR PRECOAT 5950-17-02
|
Facility
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,114.00 |
| Max. Negotiated Rate |
$17,112.00 |
| Rate for Payer: Aetna Commercial |
$16,740.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,858.00
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,112.00
|
| Rate for Payer: Health EOS Commercial |
$16,554.00
|
| Rate for Payer: HFN Commercial |
$17,112.00
|
| Rate for Payer: Multiplan Commercial |
$14,880.00
|
| Rate for Payer: NAPHCARE Commercial |
$11,160.00
|
| Rate for Payer: Preferred Network Access Commercial |
$17,112.00
|
| Rate for Payer: Quartz Beloit One Network |
$9,114.00
|
| Rate for Payer: Quartz Commercial |
$11,160.00
|
| Rate for Payer: WEA Trust Commercial |
$10,230.00
|
| Rate for Payer: WPS Commercial |
$13,777.02
|
|
|
COMPONENT FEM G-RT GSF FLEX CR 00-5750-017-02
|
Facility
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM G-RT GSF FLEX CR 00-5750-017-02
|
Facility
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967679
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,031.32 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM GSF F-LT FLEX CR 00-5750-016-01
|
Facility
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM GSF F-LT FLEX CR 00-5750-016-01
|
Facility
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,031.32 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM GSF F-RT FLEX CR 00-5750-016-02
|
Facility
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,804.81 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM GSF F-RT FLEX CR 00-5750-016-02
|
Facility
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,031.32 |
| Max. Negotiated Rate |
$16,531.48 |
| Rate for Payer: Aetna Commercial |
$16,172.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,453.34
|
| Rate for Payer: Aetna Managed Medicare |
$5,031.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,679.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,984.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,625.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,523.57
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$16,531.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,055.45
|
| Rate for Payer: Health EOS Commercial |
$15,992.41
|
| Rate for Payer: HFN Commercial |
$16,531.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,476.75
|
| Rate for Payer: Multiplan Commercial |
$14,375.20
|
| Rate for Payer: NAPHCARE Commercial |
$10,781.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,531.48
|
| Rate for Payer: Quartz Beloit One Network |
$8,804.81
|
| Rate for Payer: Quartz Commercial |
$11,679.85
|
| Rate for Payer: Quartz Medicare Advantage |
$10,781.40
|
| Rate for Payer: WEA Trust Commercial |
$9,882.95
|
| Rate for Payer: WPS Commercial |
$13,309.64
|
|
|
COMPONENT FEM H-LT CR PRECOAT 5970-18-01
|
Facility
IP
|
$11,398.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,585.02 |
| Max. Negotiated Rate |
$10,486.16 |
| Rate for Payer: Aetna Commercial |
$10,258.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,040.94
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,486.16
|
| Rate for Payer: Health EOS Commercial |
$10,144.22
|
| Rate for Payer: HFN Commercial |
$10,486.16
|
| Rate for Payer: Multiplan Commercial |
$9,118.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,838.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,486.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,585.02
|
| Rate for Payer: Quartz Commercial |
$6,838.80
|
| Rate for Payer: WEA Trust Commercial |
$6,268.90
|
| Rate for Payer: WPS Commercial |
$8,442.50
|
|
|
COMPONENT FEM H-LT CR PRECOAT 5970-18-01
|
Facility
OP
|
$11,398.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967680
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,191.44 |
| Max. Negotiated Rate |
$10,486.16 |
| Rate for Payer: Aetna Commercial |
$10,258.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,802.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,191.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,408.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,699.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,471.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,040.94
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,486.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,378.32
|
| Rate for Payer: Health EOS Commercial |
$10,144.22
|
| Rate for Payer: HFN Commercial |
$10,486.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,548.50
|
| Rate for Payer: Multiplan Commercial |
$9,118.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,838.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,486.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,585.02
|
| Rate for Payer: Quartz Commercial |
$7,408.70
|
| Rate for Payer: Quartz Medicare Advantage |
$6,838.80
|
| Rate for Payer: WEA Trust Commercial |
$6,268.90
|
| Rate for Payer: WPS Commercial |
$8,442.50
|
|
|
COMPONENT FEM H-RT CR PRECOAT 5970-18-02
|
Facility
IP
|
$11,398.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,585.02 |
| Max. Negotiated Rate |
$10,486.16 |
| Rate for Payer: Aetna Commercial |
$10,258.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,040.94
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,486.16
|
| Rate for Payer: Health EOS Commercial |
$10,144.22
|
| Rate for Payer: HFN Commercial |
$10,486.16
|
| Rate for Payer: Multiplan Commercial |
$9,118.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,838.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,486.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,585.02
|
| Rate for Payer: Quartz Commercial |
$6,838.80
|
| Rate for Payer: WEA Trust Commercial |
$6,268.90
|
| Rate for Payer: WPS Commercial |
$8,442.50
|
|
|
COMPONENT FEM H-RT CR PRECOAT 5970-18-02
|
Facility
OP
|
$11,398.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967681
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,191.44 |
| Max. Negotiated Rate |
$10,486.16 |
| Rate for Payer: Aetna Commercial |
$10,258.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,802.28
|
| Rate for Payer: Aetna Managed Medicare |
$3,191.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,408.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,699.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,471.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,040.94
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,486.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,378.32
|
| Rate for Payer: Health EOS Commercial |
$10,144.22
|
| Rate for Payer: HFN Commercial |
$10,486.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,548.50
|
| Rate for Payer: Multiplan Commercial |
$9,118.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,838.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,486.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,585.02
|
| Rate for Payer: Quartz Commercial |
$7,408.70
|
| Rate for Payer: Quartz Medicare Advantage |
$6,838.80
|
| Rate for Payer: WEA Trust Commercial |
$6,268.90
|
| Rate for Payer: WPS Commercial |
$8,442.50
|
|
|
Comprehensive Audiology Eval
|
Professional
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Aetna Managed Medicare |
$30.85
|
| Rate for Payer: Anthem Medicare Advantage |
$30.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.85
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$262.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.85
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$273.60
|
| Rate for Payer: Quartz Beloit One Network |
$126.72
|
| Rate for Payer: Quartz Commercial |
$164.16
|
| Rate for Payer: Quartz Medicare Advantage |
$30.85
|
| Rate for Payer: The Alliance Commercial |
$77.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.85
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$123.40
|
|
|
Comprehensive Audiology Eval
|
Facility
OP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$138.24 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.24
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Comprehensive Audiology Eval
|
Facility
IP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$141.12 |
| Max. Negotiated Rate |
$264.96 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$172.80
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Comprehensive Hereditary Cancer Panel
|
Professional
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$372.68 |
| Max. Negotiated Rate |
$2,987.82 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$728.42
|
| Rate for Payer: Aetna Managed Medicare |
$679.05
|
| Rate for Payer: Anthem Medicare Advantage |
$679.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$679.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$679.05
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$804.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$423.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$679.05
|
| Rate for Payer: Health EOS Commercial |
$770.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,397.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$679.05
|
| Rate for Payer: Multiplan Commercial |
$677.60
|
| Rate for Payer: Preferred Network Access Commercial |
$804.65
|
| Rate for Payer: Quartz Beloit One Network |
$372.68
|
| Rate for Payer: Quartz Commercial |
$482.79
|
| Rate for Payer: Quartz Medicare Advantage |
$679.05
|
| Rate for Payer: The Alliance Commercial |
$2,682.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$679.05
|
| Rate for Payer: WEA Trust Commercial |
$465.85
|
| Rate for Payer: WPS Commercial |
$2,987.82
|
|
|
Comprehensive Hereditary Cancer Panel
|
Facility
OP
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$415.03 |
| Max. Negotiated Rate |
$3,388.00 |
| Rate for Payer: Aetna Commercial |
$762.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$728.42
|
| Rate for Payer: Aetna Managed Medicare |
$679.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,546.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,188.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,127.22
|
| Rate for Payer: Anthem Medicare Advantage |
$679.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$679.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$679.05
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$779.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$679.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$679.05
|
| Rate for Payer: Health EOS Commercial |
$753.83
|
| Rate for Payer: HFN Commercial |
$779.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,526.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$679.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$679.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$679.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$679.05
|
| Rate for Payer: Multiplan Commercial |
$677.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,018.58
|
| Rate for Payer: Preferred Network Access Commercial |
$779.24
|
| Rate for Payer: Quartz Beloit One Network |
$415.03
|
| Rate for Payer: Quartz Commercial |
$550.55
|
| Rate for Payer: Quartz Medicare Advantage |
$679.05
|
| Rate for Payer: The Alliance Commercial |
$3,388.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$679.05
|
| Rate for Payer: United Healthcare PPO |
$635.25
|
| Rate for Payer: WEA Trust Commercial |
$465.85
|
| Rate for Payer: Wellcare Medicare |
$679.05
|
| Rate for Payer: WPS Commercial |
$627.37
|
|
|
Comprehensive Hereditary Cancer Panel
|
Facility
IP
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$415.03 |
| Max. Negotiated Rate |
$779.24 |
| Rate for Payer: Aetna Commercial |
$762.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.91
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$779.24
|
| Rate for Payer: Health EOS Commercial |
$753.83
|
| Rate for Payer: HFN Commercial |
$779.24
|
| Rate for Payer: Multiplan Commercial |
$677.60
|
| Rate for Payer: NAPHCARE Commercial |
$508.20
|
| Rate for Payer: Preferred Network Access Commercial |
$779.24
|
| Rate for Payer: Quartz Beloit One Network |
$415.03
|
| Rate for Payer: Quartz Commercial |
$508.20
|
| Rate for Payer: WEA Trust Commercial |
$465.85
|
| Rate for Payer: WPS Commercial |
$627.37
|
|
|
Comprehensive Metabolic Panel
|
Professional
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$320.15 |
| Rate for Payer: Aetna Commercial |
$320.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.56
|
| Rate for Payer: Anthem Medicare Advantage |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.56
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$320.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$168.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.56
|
| Rate for Payer: Health EOS Commercial |
$306.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.56
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: Preferred Network Access Commercial |
$320.15
|
| Rate for Payer: Quartz Beloit One Network |
$148.28
|
| Rate for Payer: Quartz Commercial |
$192.09
|
| Rate for Payer: Quartz Medicare Advantage |
$10.56
|
| Rate for Payer: The Alliance Commercial |
$41.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.56
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: WPS Commercial |
$46.46
|
|
|
Comprehensive Metabolic Panel
|
Facility
OP
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$1,348.00 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$289.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.53
|
| Rate for Payer: Anthem Medicaid |
$10.91
|
| Rate for Payer: Anthem Medicare Advantage |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.56
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.91
|
| Rate for Payer: Dean Health Medicaid |
$10.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.56
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.56
|
| Rate for Payer: Managed Health Services Medicaid |
$11.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.56
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$15.84
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10.91
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$219.05
|
| Rate for Payer: Quartz Medicare Advantage |
$10.56
|
| Rate for Payer: The Alliance Commercial |
$1,348.00
|
| Rate for Payer: United Healthcare Medicaid |
$10.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.56
|
| Rate for Payer: United Healthcare PPO |
$252.75
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: Wellcare Medicare |
$10.56
|
| Rate for Payer: WMAP Medicaid |
$10.91
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
Comprehensive Metabolic Panel
|
Facility
IP
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$165.13 |
| Max. Negotiated Rate |
$310.04 |
| Rate for Payer: Aetna Commercial |
$303.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$178.61
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$310.04
|
| Rate for Payer: Health EOS Commercial |
$299.93
|
| Rate for Payer: HFN Commercial |
$310.04
|
| Rate for Payer: Multiplan Commercial |
$269.60
|
| Rate for Payer: NAPHCARE Commercial |
$202.20
|
| Rate for Payer: Preferred Network Access Commercial |
$310.04
|
| Rate for Payer: Quartz Beloit One Network |
$165.13
|
| Rate for Payer: Quartz Commercial |
$202.20
|
| Rate for Payer: WEA Trust Commercial |
$185.35
|
| Rate for Payer: WPS Commercial |
$249.62
|
|
|
COMPRESSION GLOVER 3/4 SM (L) #9274-40-02
|
Facility
OP
|
$258.00
|
|
| Hospital Charge Code |
2969808
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$72.24 |
| Max. Negotiated Rate |
$1,032.00 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Aetna Managed Medicare |
$72.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$129.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.38
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.50
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$167.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.80
|
| Rate for Payer: The Alliance Commercial |
$1,032.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
COMPRESSION GLOVER 3/4 SM (L) #9274-40-02
|
Facility
IP
|
$258.00
|
|
| Hospital Charge Code |
2969808
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$126.42 |
| Max. Negotiated Rate |
$237.36 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
COMPRESSION PLATE 5.0 BROAD 11 HL 627571
|
Facility
OP
|
$9,835.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175223
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,753.80 |
| Max. Negotiated Rate |
$9,048.20 |
| Rate for Payer: Aetna Commercial |
$8,851.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,458.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,753.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,392.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,917.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,720.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,212.55
|
| Rate for Payer: Cash Price |
$2,950.50
|
| Rate for Payer: Cigna Commercial |
$9,048.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,503.67
|
| Rate for Payer: Health EOS Commercial |
$8,753.15
|
| Rate for Payer: HFN Commercial |
$9,048.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,376.25
|
| Rate for Payer: Multiplan Commercial |
$7,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,901.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,048.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,819.15
|
| Rate for Payer: Quartz Commercial |
$6,392.75
|
| Rate for Payer: Quartz Medicare Advantage |
$5,901.00
|
| Rate for Payer: WEA Trust Commercial |
$5,409.25
|
| Rate for Payer: WPS Commercial |
$7,284.78
|
|
