|
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 |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
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 |
$3,319.10 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Aetna Managed Medicare |
$3,319.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,705.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,926.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,689.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,633.64
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,890.44
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: NAPHCARE Commercial |
$7,112.35
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,705.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,112.35
|
| Rate for Payer: The Alliance Commercial |
$5,926.96
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
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 |
$5,808.42 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,112.35
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
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 |
$5,808.42 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,112.35
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
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 |
$3,319.10 |
| Max. Negotiated Rate |
$10,905.61 |
| Rate for Payer: Aetna Commercial |
$10,668.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,194.37
|
| Rate for Payer: Aetna Managed Medicare |
$3,319.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,705.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,926.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,689.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,282.58
|
| Rate for Payer: Cash Price |
$3,419.40
|
| Rate for Payer: Cigna Commercial |
$10,905.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,633.64
|
| Rate for Payer: Health EOS Commercial |
$10,549.99
|
| Rate for Payer: HFN Commercial |
$10,905.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,890.44
|
| Rate for Payer: Multiplan Commercial |
$9,483.14
|
| Rate for Payer: NAPHCARE Commercial |
$7,112.35
|
| Rate for Payer: Preferred Network Access Commercial |
$10,905.61
|
| Rate for Payer: Quartz Beloit One Network |
$5,808.42
|
| Rate for Payer: Quartz Commercial |
$7,705.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,112.35
|
| Rate for Payer: The Alliance Commercial |
$5,926.96
|
| Rate for Payer: WEA Trust Commercial |
$6,519.66
|
| Rate for Payer: WPS Commercial |
$8,779.88
|
|
|
Comprehensive Audiology Eval
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$275.56 |
| Rate for Payer: Aetna Commercial |
$269.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.75
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: Health EOS Commercial |
$266.57
|
| Rate for Payer: HFN Commercial |
$275.56
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: Preferred Network Access Commercial |
$275.56
|
| Rate for Payer: Quartz Beloit One Network |
$146.76
|
| Rate for Payer: Quartz Commercial |
$179.71
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: WPS Commercial |
$221.85
|
|
|
Comprehensive Audiology Eval
|
Professional
|
Both
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.27 |
| Max. Negotiated Rate |
$284.54 |
| Rate for Payer: Aetna Commercial |
$284.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Aetna Managed Medicare |
$26.27
|
| Rate for Payer: Anthem Medicare Advantage |
$26.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.27
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$284.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.27
|
| Rate for Payer: Health EOS Commercial |
$272.56
|
| Rate for Payer: HFN Commercial |
$284.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.27
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: NAPHCARE Commercial |
$39.41
|
| Rate for Payer: Preferred Network Access Commercial |
$284.54
|
| Rate for Payer: Quartz Beloit One Network |
$131.79
|
| Rate for Payer: Quartz Commercial |
$170.73
|
| Rate for Payer: Quartz Medicare Advantage |
$26.27
|
| Rate for Payer: The Alliance Commercial |
$65.68
|
| Rate for Payer: United Healthcare Medicaid |
$41.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.27
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: WPS Commercial |
$105.08
|
|
|
Comprehensive Audiology Eval
|
Facility
|
OP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
3203512
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$135.42 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$269.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$194.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$149.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$143.77
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.42
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$266.57
|
| Rate for Payer: HFN Commercial |
$275.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.42
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$275.56
|
| Rate for Payer: Quartz Beloit One Network |
$146.76
|
| Rate for Payer: Quartz Commercial |
$194.69
|
| Rate for Payer: Quartz Medicare Advantage |
$135.42
|
| Rate for Payer: The Alliance Commercial |
$541.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.42
|
| Rate for Payer: United Healthcare PPO |
$224.64
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$221.85
|
|
|
Comprehensive Hereditary Cancer Panel
|
Facility
|
IP
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$431.63 |
| Max. Negotiated Rate |
$810.41 |
| Rate for Payer: Aetna Commercial |
$792.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$466.87
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$810.41
|
| Rate for Payer: Health EOS Commercial |
$783.98
|
| Rate for Payer: HFN Commercial |
$810.41
|
| Rate for Payer: Multiplan Commercial |
$704.70
|
| Rate for Payer: Preferred Network Access Commercial |
$810.41
|
| Rate for Payer: Quartz Beloit One Network |
$431.63
|
| Rate for Payer: Quartz Commercial |
$528.53
|
| Rate for Payer: WEA Trust Commercial |
$484.48
|
| Rate for Payer: WPS Commercial |
$652.44
|
|
|
Comprehensive Hereditary Cancer Panel
|
Facility
|
OP
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$431.63 |
| Max. Negotiated Rate |
$5,424.43 |
| Rate for Payer: Aetna Commercial |
$792.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,648.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,235.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,172.31
|
| Rate for Payer: Anthem Medicare Advantage |
$1,356.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$466.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,356.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,356.11
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$810.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,356.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$492.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,356.11
|
| Rate for Payer: Health EOS Commercial |
$783.98
|
| Rate for Payer: HFN Commercial |
$810.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,044.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,356.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,356.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,356.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,356.11
|
| Rate for Payer: Multiplan Commercial |
$704.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,034.16
|
| Rate for Payer: Preferred Network Access Commercial |
$810.41
|
| Rate for Payer: Quartz Beloit One Network |
$431.63
|
| Rate for Payer: Quartz Commercial |
$572.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,356.11
|
| Rate for Payer: The Alliance Commercial |
$5,424.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,356.11
|
| Rate for Payer: United Healthcare PPO |
$660.66
|
| Rate for Payer: WEA Trust Commercial |
$484.48
|
| Rate for Payer: Wellcare Medicare |
$1,356.11
|
| Rate for Payer: WPS Commercial |
$652.44
|
|
|
Comprehensive Hereditary Cancer Panel
|
Professional
|
Both
|
$847.00
|
|
|
Service Code
|
CPT 81432
|
| Hospital Charge Code |
6173422
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$387.59 |
| Max. Negotiated Rate |
$5,966.88 |
| Rate for Payer: Aetna Commercial |
$836.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.11
|
| Rate for Payer: Anthem Medicare Advantage |
$1,356.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,356.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,356.11
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cash Price |
$254.10
|
| Rate for Payer: Cigna Commercial |
$836.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$440.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,356.11
|
| Rate for Payer: Health EOS Commercial |
$801.60
|
| Rate for Payer: HFN Commercial |
$836.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,492.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,492.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,356.11
|
| Rate for Payer: Multiplan Commercial |
$704.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,034.16
|
| Rate for Payer: Preferred Network Access Commercial |
$836.84
|
| Rate for Payer: Quartz Beloit One Network |
$387.59
|
| Rate for Payer: Quartz Commercial |
$502.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,356.11
|
| Rate for Payer: The Alliance Commercial |
$5,356.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,356.11
|
| Rate for Payer: WEA Trust Commercial |
$484.48
|
| Rate for Payer: WPS Commercial |
$5,966.88
|
|
|
Comprehensive Metabolic Panel
|
Professional
|
Both
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$332.96 |
| Rate for Payer: Aetna Commercial |
$332.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Aetna Managed Medicare |
$10.98
|
| Rate for Payer: Anthem Medicare Advantage |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.98
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$332.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$175.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.98
|
| Rate for Payer: Health EOS Commercial |
$318.94
|
| Rate for Payer: HFN Commercial |
$332.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.98
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: NAPHCARE Commercial |
$16.47
|
| Rate for Payer: Preferred Network Access Commercial |
$332.96
|
| Rate for Payer: Quartz Beloit One Network |
$154.21
|
| Rate for Payer: Quartz Commercial |
$199.77
|
| Rate for Payer: Quartz Medicare Advantage |
$10.98
|
| Rate for Payer: The Alliance Commercial |
$43.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.98
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: WPS Commercial |
$48.32
|
|
|
Comprehensive Metabolic Panel
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$171.74 |
| Max. Negotiated Rate |
$322.44 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$210.29
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Comprehensive Metabolic Panel
|
Facility
|
OP
|
$337.00
|
|
|
Service Code
|
CPT 80053
|
| Hospital Charge Code |
633709
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$322.44 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Aetna Managed Medicare |
$10.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.23
|
| Rate for Payer: Anthem Medicare Advantage |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.98
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.98
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.98
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: NAPHCARE Commercial |
$16.47
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$227.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10.98
|
| Rate for Payer: The Alliance Commercial |
$43.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.98
|
| Rate for Payer: United Healthcare PPO |
$262.86
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: Wellcare Medicare |
$10.98
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Comprehensive metabolic panel this panel must include the following: albumin (82040) bilirubin, total (82247) calcium, total (82310) carbon dioxide (bicarbonate) (82374) chloride (82435) creatinine (82565) glucose (82947) phosphatase, alkaline (84075) potassium (84132) protein, total (84155) sodium (84295) transferase, alanine amino (ALT) (SGPT) (84460) transferase, aspartate amino (AST) (SGOT) (84450) urea nitrogen (BUN) (84520)
|
Facility
|
OP
|
$43.93
|
|
|
Service Code
|
CPT 80053
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$43.93 |
| Rate for Payer: Aetna Managed Medicare |
$10.98
|
| Rate for Payer: Anthem Medicare Advantage |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.98
|
| Rate for Payer: NAPHCARE Commercial |
$16.47
|
| Rate for Payer: Quartz Medicare Advantage |
$10.98
|
| Rate for Payer: The Alliance Commercial |
$43.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.98
|
| Rate for Payer: Wellcare Medicare |
$10.98
|
|
|
COMPRESSION GLOVER 3/4 SM (L) #9274-40-02
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
2969808
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$160.99
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
COMPRESSION GLOVER 3/4 SM (L) #9274-40-02
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
2969808
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$75.13 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$75.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.16
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.24
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$160.99
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$174.41
|
| Rate for Payer: Quartz Medicare Advantage |
$160.99
|
| Rate for Payer: The Alliance Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
COMPRESSION PLATE 5.0 BROAD 11 HL 627571
|
Facility
|
IP
|
$9,835.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175223
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,011.92 |
| Max. Negotiated Rate |
$9,410.13 |
| Rate for Payer: Aetna Commercial |
$9,205.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,796.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,421.05
|
| Rate for Payer: Cash Price |
$2,950.50
|
| Rate for Payer: Cigna Commercial |
$9,410.13
|
| Rate for Payer: Health EOS Commercial |
$9,103.28
|
| Rate for Payer: HFN Commercial |
$9,410.13
|
| Rate for Payer: Multiplan Commercial |
$8,182.72
|
| Rate for Payer: Preferred Network Access Commercial |
$9,410.13
|
| Rate for Payer: Quartz Beloit One Network |
$5,011.92
|
| Rate for Payer: Quartz Commercial |
$6,137.04
|
| Rate for Payer: WEA Trust Commercial |
$5,625.62
|
| Rate for Payer: WPS Commercial |
$7,575.90
|
|
|
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 |
$2,863.95 |
| Max. Negotiated Rate |
$9,410.13 |
| Rate for Payer: Aetna Commercial |
$9,205.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,796.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,863.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,648.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,114.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,909.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,421.05
|
| Rate for Payer: Cash Price |
$2,950.50
|
| Rate for Payer: Cigna Commercial |
$9,410.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,723.97
|
| Rate for Payer: Health EOS Commercial |
$9,103.28
|
| Rate for Payer: HFN Commercial |
$9,410.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,671.30
|
| Rate for Payer: Multiplan Commercial |
$8,182.72
|
| Rate for Payer: NAPHCARE Commercial |
$6,137.04
|
| Rate for Payer: Preferred Network Access Commercial |
$9,410.13
|
| Rate for Payer: Quartz Beloit One Network |
$5,011.92
|
| Rate for Payer: Quartz Commercial |
$6,648.46
|
| Rate for Payer: Quartz Medicare Advantage |
$6,137.04
|
| Rate for Payer: The Alliance Commercial |
$5,114.20
|
| Rate for Payer: WEA Trust Commercial |
$5,625.62
|
| Rate for Payer: WPS Commercial |
$7,575.90
|
|
|
COMPRESSION SCREW 32.3MM OMEGA 596001S
|
Facility
|
IP
|
$894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5459544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$455.58 |
| Max. Negotiated Rate |
$855.38 |
| Rate for Payer: Aetna Commercial |
$836.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$799.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$492.77
|
| Rate for Payer: Cash Price |
$268.20
|
| Rate for Payer: Cigna Commercial |
$855.38
|
| Rate for Payer: Health EOS Commercial |
$827.49
|
| Rate for Payer: HFN Commercial |
$855.38
|
| Rate for Payer: Multiplan Commercial |
$743.81
|
| Rate for Payer: Preferred Network Access Commercial |
$855.38
|
| Rate for Payer: Quartz Beloit One Network |
$455.58
|
| Rate for Payer: Quartz Commercial |
$557.86
|
| Rate for Payer: WEA Trust Commercial |
$511.37
|
| Rate for Payer: WPS Commercial |
$688.65
|
|
|
COMPRESSION SCREW 32.3MM OMEGA 596001S
|
Facility
|
OP
|
$894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5459544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$260.33 |
| Max. Negotiated Rate |
$855.38 |
| Rate for Payer: Aetna Commercial |
$836.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$799.59
|
| Rate for Payer: Aetna Managed Medicare |
$260.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$604.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$464.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$446.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$492.77
|
| Rate for Payer: Cash Price |
$268.20
|
| Rate for Payer: Cigna Commercial |
$855.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$520.31
|
| Rate for Payer: Health EOS Commercial |
$827.49
|
| Rate for Payer: HFN Commercial |
$855.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$697.32
|
| Rate for Payer: Multiplan Commercial |
$743.81
|
| Rate for Payer: NAPHCARE Commercial |
$557.86
|
| Rate for Payer: Preferred Network Access Commercial |
$855.38
|
| Rate for Payer: Quartz Beloit One Network |
$455.58
|
| Rate for Payer: Quartz Commercial |
$604.34
|
| Rate for Payer: Quartz Medicare Advantage |
$557.86
|
| Rate for Payer: The Alliance Commercial |
$464.88
|
| Rate for Payer: WEA Trust Commercial |
$511.37
|
| Rate for Payer: WPS Commercial |
$688.65
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 18MM SCREW WHITE EQUINOXE REVERSE SHOULDER 320-20-18
|
Facility
|
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$331.35 |
| Max. Negotiated Rate |
$1,088.73 |
| Rate for Payer: Aetna Commercial |
$1,065.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,017.73
|
| Rate for Payer: Aetna Managed Medicare |
$331.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$769.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$591.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$568.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$627.20
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,088.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$662.25
|
| Rate for Payer: Health EOS Commercial |
$1,053.23
|
| Rate for Payer: HFN Commercial |
$1,088.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$887.55
|
| Rate for Payer: Multiplan Commercial |
$946.72
|
| Rate for Payer: NAPHCARE Commercial |
$710.04
|
| Rate for Payer: Preferred Network Access Commercial |
$1,088.73
|
| Rate for Payer: Quartz Beloit One Network |
$579.87
|
| Rate for Payer: Quartz Commercial |
$769.21
|
| Rate for Payer: Quartz Medicare Advantage |
$710.04
|
| Rate for Payer: The Alliance Commercial |
$591.70
|
| Rate for Payer: WEA Trust Commercial |
$650.87
|
| Rate for Payer: WPS Commercial |
$876.52
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 18MM SCREW WHITE EQUINOXE REVERSE SHOULDER 320-20-18
|
Facility
|
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$579.87 |
| Max. Negotiated Rate |
$1,088.73 |
| Rate for Payer: Aetna Commercial |
$1,065.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,017.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$627.20
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,088.73
|
| Rate for Payer: Health EOS Commercial |
$1,053.23
|
| Rate for Payer: HFN Commercial |
$1,088.73
|
| Rate for Payer: Multiplan Commercial |
$946.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,088.73
|
| Rate for Payer: Quartz Beloit One Network |
$579.87
|
| Rate for Payer: Quartz Commercial |
$710.04
|
| Rate for Payer: WEA Trust Commercial |
$650.87
|
| Rate for Payer: WPS Commercial |
$876.52
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 22MM SCREW BLACK EQUINOXE REVERSE SHOULDER 320-20-22
|
Facility
|
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$579.87 |
| Max. Negotiated Rate |
$1,088.73 |
| Rate for Payer: Aetna Commercial |
$1,065.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,017.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$627.20
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,088.73
|
| Rate for Payer: Health EOS Commercial |
$1,053.23
|
| Rate for Payer: HFN Commercial |
$1,088.73
|
| Rate for Payer: Multiplan Commercial |
$946.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,088.73
|
| Rate for Payer: Quartz Beloit One Network |
$579.87
|
| Rate for Payer: Quartz Commercial |
$710.04
|
| Rate for Payer: WEA Trust Commercial |
$650.87
|
| Rate for Payer: WPS Commercial |
$876.52
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 22MM SCREW BLACK EQUINOXE REVERSE SHOULDER 320-20-22
|
Facility
|
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$331.35 |
| Max. Negotiated Rate |
$1,088.73 |
| Rate for Payer: Aetna Commercial |
$1,065.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,017.73
|
| Rate for Payer: Aetna Managed Medicare |
$331.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$769.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$591.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$568.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$627.20
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,088.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$662.25
|
| Rate for Payer: Health EOS Commercial |
$1,053.23
|
| Rate for Payer: HFN Commercial |
$1,088.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$887.55
|
| Rate for Payer: Multiplan Commercial |
$946.72
|
| Rate for Payer: NAPHCARE Commercial |
$710.04
|
| Rate for Payer: Preferred Network Access Commercial |
$1,088.73
|
| Rate for Payer: Quartz Beloit One Network |
$579.87
|
| Rate for Payer: Quartz Commercial |
$769.21
|
| Rate for Payer: Quartz Medicare Advantage |
$710.04
|
| Rate for Payer: The Alliance Commercial |
$591.70
|
| Rate for Payer: WEA Trust Commercial |
$650.87
|
| Rate for Payer: WPS Commercial |
$876.52
|
|
