|
CONNECTOR V.A.C. Y M6275066/10
|
Facility
OP
|
$98.00
|
|
| Hospital Charge Code |
4508601
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
CONNECTOR Y 1/4 X 1/2 X 1/2 341244-000
|
Facility
OP
|
$193.00
|
|
| Hospital Charge Code |
2965785
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.75
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y 1/4 X 1/2 X 1/2 341244-000
|
Facility
IP
|
$193.00
|
|
| Hospital Charge Code |
2965785
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y 1/4 X 3/8 X 3/8 341233-000
|
Facility
IP
|
$193.00
|
|
| Hospital Charge Code |
2965786
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y 1/4 X 3/8 X 3/8 341233-000
|
Facility
OP
|
$193.00
|
|
| Hospital Charge Code |
2965786
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.75
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y 3/8x3/8x3/8 C330SP
|
Facility
OP
|
$193.00
|
|
| Hospital Charge Code |
2965784
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.75
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y 3/8x3/8x3/8 C330SP
|
Facility
IP
|
$193.00
|
|
| Hospital Charge Code |
2965784
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
CONNECTOR Y LIFESHIELD***DEDE 1/20
|
Facility
IP
|
$72.00
|
|
| Hospital Charge Code |
2963194
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
CONNECTOR Y LIFESHIELD***DEDE 1/20
|
Facility
OP
|
$72.00
|
|
| Hospital Charge Code |
2963194
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.29
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$43.20
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
CONNORS PARENT RESPONSE
|
Facility
IP
|
$63.00
|
|
| Hospital Charge Code |
2971891
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
CONNORS PARENT RESPONSE
|
Facility
OP
|
$63.00
|
|
| Hospital Charge Code |
2971891
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$37.80
|
| Rate for Payer: The Alliance Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
CONNORS TEACHER RESPONSE
|
Facility
OP
|
$63.00
|
|
| Hospital Charge Code |
2971892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$37.80
|
| Rate for Payer: The Alliance Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
CONNORS TEACHER RESPONSE
|
Facility
IP
|
$63.00
|
|
| Hospital Charge Code |
2971892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Consult, Brief
|
Facility
OP
|
$297.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040412
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$83.16 |
| Max. Negotiated Rate |
$273.24 |
| Rate for Payer: Aetna Commercial |
$267.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.42
|
| Rate for Payer: Aetna Managed Medicare |
$83.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$193.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.41
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$273.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.20
|
| Rate for Payer: Health EOS Commercial |
$264.33
|
| Rate for Payer: HFN Commercial |
$273.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.75
|
| Rate for Payer: Multiplan Commercial |
$237.60
|
| Rate for Payer: NAPHCARE Commercial |
$178.20
|
| Rate for Payer: Preferred Network Access Commercial |
$273.24
|
| Rate for Payer: Quartz Beloit One Network |
$145.53
|
| Rate for Payer: Quartz Commercial |
$193.05
|
| Rate for Payer: Quartz Medicare Advantage |
$178.20
|
| Rate for Payer: WEA Trust Commercial |
$163.35
|
| Rate for Payer: WPS Commercial |
$219.99
|
|
|
Consult, Brief
|
Facility
IP
|
$297.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040412
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$145.53 |
| Max. Negotiated Rate |
$273.24 |
| Rate for Payer: Aetna Commercial |
$267.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.41
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$273.24
|
| Rate for Payer: Health EOS Commercial |
$264.33
|
| Rate for Payer: HFN Commercial |
$273.24
|
| Rate for Payer: Multiplan Commercial |
$237.60
|
| Rate for Payer: NAPHCARE Commercial |
$178.20
|
| Rate for Payer: Preferred Network Access Commercial |
$273.24
|
| Rate for Payer: Quartz Beloit One Network |
$145.53
|
| Rate for Payer: Quartz Commercial |
$178.20
|
| Rate for Payer: WEA Trust Commercial |
$163.35
|
| Rate for Payer: WPS Commercial |
$219.99
|
|
|
Consult, Extended
|
Facility
OP
|
$443.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$124.04 |
| Max. Negotiated Rate |
$407.56 |
| Rate for Payer: Aetna Commercial |
$398.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.98
|
| Rate for Payer: Aetna Managed Medicare |
$124.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$287.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$221.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$212.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.79
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$407.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$247.90
|
| Rate for Payer: Health EOS Commercial |
$394.27
|
| Rate for Payer: HFN Commercial |
$407.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$332.25
|
| Rate for Payer: Multiplan Commercial |
$354.40
|
| Rate for Payer: NAPHCARE Commercial |
$265.80
|
| Rate for Payer: Preferred Network Access Commercial |
$407.56
|
| Rate for Payer: Quartz Beloit One Network |
$217.07
|
| Rate for Payer: Quartz Commercial |
$287.95
|
| Rate for Payer: Quartz Medicare Advantage |
$265.80
|
| Rate for Payer: WEA Trust Commercial |
$243.65
|
| Rate for Payer: WPS Commercial |
$328.13
|
|
|
Consult, Extended
|
Facility
IP
|
$443.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$217.07 |
| Max. Negotiated Rate |
$407.56 |
| Rate for Payer: Aetna Commercial |
$398.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.79
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$407.56
|
| Rate for Payer: Health EOS Commercial |
$394.27
|
| Rate for Payer: HFN Commercial |
$407.56
|
| Rate for Payer: Multiplan Commercial |
$354.40
|
| Rate for Payer: NAPHCARE Commercial |
$265.80
|
| Rate for Payer: Preferred Network Access Commercial |
$407.56
|
| Rate for Payer: Quartz Beloit One Network |
$217.07
|
| Rate for Payer: Quartz Commercial |
$265.80
|
| Rate for Payer: WEA Trust Commercial |
$243.65
|
| Rate for Payer: WPS Commercial |
$328.13
|
|
|
Consult, Routine
|
Facility
OP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$102.76 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Aetna Managed Medicare |
$102.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$238.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$183.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.37
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.25
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$238.55
|
| Rate for Payer: Quartz Medicare Advantage |
$220.20
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
Consult, Routine
|
Facility
IP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$179.83 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$220.20
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
CONTACT ISOLATION CART
|
Facility
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$381.92 |
| Max. Negotiated Rate |
$5,456.00 |
| Rate for Payer: Aetna Commercial |
$1,227.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,173.04
|
| Rate for Payer: Aetna Managed Medicare |
$381.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$886.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$682.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$654.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.92
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,254.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$763.29
|
| Rate for Payer: Health EOS Commercial |
$1,213.96
|
| Rate for Payer: HFN Commercial |
$1,254.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,023.00
|
| Rate for Payer: Multiplan Commercial |
$1,091.20
|
| Rate for Payer: NAPHCARE Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,254.88
|
| Rate for Payer: Quartz Beloit One Network |
$668.36
|
| Rate for Payer: Quartz Commercial |
$886.60
|
| Rate for Payer: Quartz Medicare Advantage |
$818.40
|
| Rate for Payer: The Alliance Commercial |
$5,456.00
|
| Rate for Payer: WEA Trust Commercial |
$750.20
|
| Rate for Payer: WPS Commercial |
$1,010.31
|
|
|
CONTACT ISOLATION CART
|
Facility
IP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$668.36 |
| Max. Negotiated Rate |
$1,254.88 |
| Rate for Payer: Aetna Commercial |
$1,227.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.92
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,254.88
|
| Rate for Payer: Health EOS Commercial |
$1,213.96
|
| Rate for Payer: HFN Commercial |
$1,254.88
|
| Rate for Payer: Multiplan Commercial |
$1,091.20
|
| Rate for Payer: NAPHCARE Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,254.88
|
| Rate for Payer: Quartz Beloit One Network |
$668.36
|
| Rate for Payer: Quartz Commercial |
$818.40
|
| Rate for Payer: WEA Trust Commercial |
$750.20
|
| Rate for Payer: WPS Commercial |
$1,010.31
|
|
|
Contact - Isolation Required
|
Facility
IP
|
$1,364.00
|
|
| Hospital Charge Code |
3031396
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$668.36 |
| Max. Negotiated Rate |
$1,254.88 |
| Rate for Payer: Aetna Commercial |
$1,227.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.92
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,254.88
|
| Rate for Payer: Health EOS Commercial |
$1,213.96
|
| Rate for Payer: HFN Commercial |
$1,254.88
|
| Rate for Payer: Multiplan Commercial |
$1,091.20
|
| Rate for Payer: NAPHCARE Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,254.88
|
| Rate for Payer: Quartz Beloit One Network |
$668.36
|
| Rate for Payer: Quartz Commercial |
$818.40
|
| Rate for Payer: WEA Trust Commercial |
$750.20
|
| Rate for Payer: WPS Commercial |
$1,010.31
|
|
|
Contact - Isolation Required
|
Facility
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3031396
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$381.92 |
| Max. Negotiated Rate |
$5,456.00 |
| Rate for Payer: Aetna Commercial |
$1,227.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,173.04
|
| Rate for Payer: Aetna Managed Medicare |
$381.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$886.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$682.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$654.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$722.92
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,254.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$763.29
|
| Rate for Payer: Health EOS Commercial |
$1,213.96
|
| Rate for Payer: HFN Commercial |
$1,254.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,023.00
|
| Rate for Payer: Multiplan Commercial |
$1,091.20
|
| Rate for Payer: NAPHCARE Commercial |
$818.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,254.88
|
| Rate for Payer: Quartz Beloit One Network |
$668.36
|
| Rate for Payer: Quartz Commercial |
$886.60
|
| Rate for Payer: Quartz Medicare Advantage |
$818.40
|
| Rate for Payer: The Alliance Commercial |
$5,456.00
|
| Rate for Payer: WEA Trust Commercial |
$750.20
|
| Rate for Payer: WPS Commercial |
$1,010.31
|
|
|
Contact Lens Fitting 9231001
|
Professional
|
$54.00
|
|
|
Service Code
|
CPT 92310
|
| Hospital Charge Code |
3149554
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$349.65 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$349.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$349.65
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Contact Lens Services: Corneal Lens for Aphakia, 1 eye
|
Professional
|
$406.00
|
|
|
Service Code
|
CPT 92311
|
| Hospital Charge Code |
1122929
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna Commercial |
$385.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$50.87
|
| Rate for Payer: Anthem Medicare Advantage |
$50.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.87
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$385.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.87
|
| Rate for Payer: Health EOS Commercial |
$369.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$185.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.87
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: Preferred Network Access Commercial |
$385.70
|
| Rate for Payer: Quartz Beloit One Network |
$178.64
|
| Rate for Payer: Quartz Commercial |
$231.42
|
| Rate for Payer: Quartz Medicare Advantage |
$50.87
|
| Rate for Payer: The Alliance Commercial |
$127.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.87
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$203.48
|
|
