|
CONNECTOR SIMS/IRRIGATION
|
Facility
|
OP
|
$21.00
|
|
| Hospital Charge Code |
2963494
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$6.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.22
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$13.10
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$14.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13.10
|
| Rate for Payer: The Alliance Commercial |
$10.92
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
CONNECTOR V.A.C. Y M6275066/10
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
4508601
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
CONNECTOR V.A.C. Y M6275066/10
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
4508601
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
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 |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
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 |
$56.20 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$120.43
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$120.43
|
| Rate for Payer: The Alliance Commercial |
$100.36
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
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 |
$56.20 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$120.43
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$120.43
|
| Rate for Payer: The Alliance Commercial |
$100.36
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
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 |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
CONNECTOR Y 3/8x3/8x3/8 C330SP
|
Facility
|
OP
|
$193.00
|
|
| Hospital Charge Code |
2965784
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.54
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$120.43
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$120.43
|
| Rate for Payer: The Alliance Commercial |
$100.36
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
CONNECTOR Y 3/8x3/8x3/8 C330SP
|
Facility
|
IP
|
$193.00
|
|
| Hospital Charge Code |
2965784
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
CONNECTOR Y LIFESHIELD***DEDE 1/20
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
2963194
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
CONNECTOR Y LIFESHIELD***DEDE 1/20
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
2963194
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
CONNORS PARENT RESPONSE
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2971891
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
CONNORS PARENT RESPONSE
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2971891
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
CONNORS TEACHER RESPONSE
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2971892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
CONNORS TEACHER RESPONSE
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2971892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
CONSTIPATION
|
Facility
|
OP
|
$111.38
|
|
|
Service Code
|
EAPG 00630
|
| Min. Negotiated Rate |
$107.09 |
| Max. Negotiated Rate |
$111.38 |
| Rate for Payer: Anthem Medicaid |
$107.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$107.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.09
|
| Rate for Payer: Dean Health Medicaid |
$107.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$107.09
|
| Rate for Payer: Managed Health Services Medicaid |
$111.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$107.09
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$107.09
|
| Rate for Payer: United Healthcare Medicaid |
$107.09
|
|
|
Consult, Brief
|
Facility
|
OP
|
$297.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040412
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.49 |
| Max. Negotiated Rate |
$284.17 |
| Rate for Payer: Aetna Commercial |
$277.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$265.64
|
| Rate for Payer: Aetna Managed Medicare |
$86.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$154.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$148.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.71
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$284.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.85
|
| Rate for Payer: Health EOS Commercial |
$274.90
|
| Rate for Payer: HFN Commercial |
$284.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.66
|
| Rate for Payer: Multiplan Commercial |
$247.10
|
| Rate for Payer: NAPHCARE Commercial |
$185.33
|
| Rate for Payer: Preferred Network Access Commercial |
$284.17
|
| Rate for Payer: Quartz Beloit One Network |
$151.35
|
| Rate for Payer: Quartz Commercial |
$200.77
|
| Rate for Payer: Quartz Medicare Advantage |
$185.33
|
| Rate for Payer: The Alliance Commercial |
$122.47
|
| Rate for Payer: WEA Trust Commercial |
$169.88
|
| Rate for Payer: WPS Commercial |
$228.78
|
|
|
Consult, Brief
|
Facility
|
IP
|
$297.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3040412
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$151.35 |
| Max. Negotiated Rate |
$284.17 |
| Rate for Payer: Aetna Commercial |
$277.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$265.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.71
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$284.17
|
| Rate for Payer: Health EOS Commercial |
$274.90
|
| Rate for Payer: HFN Commercial |
$284.17
|
| Rate for Payer: Multiplan Commercial |
$247.10
|
| Rate for Payer: Preferred Network Access Commercial |
$284.17
|
| Rate for Payer: Quartz Beloit One Network |
$151.35
|
| Rate for Payer: Quartz Commercial |
$185.33
|
| Rate for Payer: WEA Trust Commercial |
$169.88
|
| Rate for Payer: WPS Commercial |
$228.78
|
|
|
Consult, Extended
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$423.86 |
| Rate for Payer: Aetna Commercial |
$414.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.22
|
| Rate for Payer: Aetna Managed Medicare |
$129.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$299.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.18
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$423.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.83
|
| Rate for Payer: Health EOS Commercial |
$410.04
|
| Rate for Payer: HFN Commercial |
$423.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$345.54
|
| Rate for Payer: Multiplan Commercial |
$368.58
|
| Rate for Payer: NAPHCARE Commercial |
$276.43
|
| Rate for Payer: Preferred Network Access Commercial |
$423.86
|
| Rate for Payer: Quartz Beloit One Network |
$225.75
|
| Rate for Payer: Quartz Commercial |
$299.47
|
| Rate for Payer: Quartz Medicare Advantage |
$276.43
|
| Rate for Payer: The Alliance Commercial |
$228.43
|
| Rate for Payer: WEA Trust Commercial |
$253.40
|
| Rate for Payer: WPS Commercial |
$341.24
|
|
|
Consult, Extended
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$225.75 |
| Max. Negotiated Rate |
$423.86 |
| Rate for Payer: Aetna Commercial |
$414.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.18
|
| Rate for Payer: Cash Price |
$132.90
|
| Rate for Payer: Cigna Commercial |
$423.86
|
| Rate for Payer: Health EOS Commercial |
$410.04
|
| Rate for Payer: HFN Commercial |
$423.86
|
| Rate for Payer: Multiplan Commercial |
$368.58
|
| Rate for Payer: Preferred Network Access Commercial |
$423.86
|
| Rate for Payer: Quartz Beloit One Network |
$225.75
|
| Rate for Payer: Quartz Commercial |
$276.43
|
| Rate for Payer: WEA Trust Commercial |
$253.40
|
| Rate for Payer: WPS Commercial |
$341.24
|
|
|
Consult, Routine
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$228.43
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Consult, Routine
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
3040413
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
CONTACT ISOLATION CART
|
Facility
|
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Aetna Managed Medicare |
$397.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$922.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$709.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.85
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.92
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: NAPHCARE Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$922.06
|
| Rate for Payer: Quartz Medicare Advantage |
$851.14
|
| Rate for Payer: The Alliance Commercial |
$709.28
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
CONTACT ISOLATION CART
|
Facility
|
IP
|
$1,364.00
|
|
| Hospital Charge Code |
3075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$695.09 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$851.14
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
|
Contact - Isolation Required
|
Facility
|
OP
|
$1,364.00
|
|
| Hospital Charge Code |
3031396
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,305.08 |
| Rate for Payer: Aetna Commercial |
$1,276.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,219.96
|
| Rate for Payer: Aetna Managed Medicare |
$397.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$922.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$709.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$680.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$751.84
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cigna Commercial |
$1,305.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$793.85
|
| Rate for Payer: Health EOS Commercial |
$1,262.52
|
| Rate for Payer: HFN Commercial |
$1,305.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.92
|
| Rate for Payer: Multiplan Commercial |
$1,134.85
|
| Rate for Payer: NAPHCARE Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.08
|
| Rate for Payer: Quartz Beloit One Network |
$695.09
|
| Rate for Payer: Quartz Commercial |
$922.06
|
| Rate for Payer: Quartz Medicare Advantage |
$851.14
|
| Rate for Payer: The Alliance Commercial |
$709.28
|
| Rate for Payer: WEA Trust Commercial |
$780.21
|
| Rate for Payer: WPS Commercial |
$1,050.69
|
|
