|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,271.00
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$6,572.41 |
| Max. Negotiated Rate |
$18,271.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,572.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,266.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,935.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,389.04
|
| Rate for Payer: Anthem Medicare Advantage |
$6,572.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,572.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,572.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,572.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,532.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,572.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,166.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,572.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,572.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,572.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,572.41
|
| Rate for Payer: NAPHCARE Commercial |
$9,858.62
|
| Rate for Payer: Quartz Medicare Advantage |
$6,572.41
|
| Rate for Payer: The Alliance Commercial |
$18,271.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,572.41
|
| Rate for Payer: United Healthcare PPO |
$10,250.21
|
| Rate for Payer: Wellcare Medicare |
$6,572.41
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
DENTAL RELATED PROCEDURE, EMERGENT CARE
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2950464
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Dental Varnish
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT D1208
|
| Hospital Charge Code |
2572837
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.40
|
| Rate for Payer: Health EOS Commercial |
$26.39
|
| Rate for Payer: HFN Commercial |
$27.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.66
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: Preferred Network Access Commercial |
$27.55
|
| Rate for Payer: Quartz Beloit One Network |
$12.76
|
| Rate for Payer: Quartz Commercial |
$16.53
|
| Rate for Payer: The Alliance Commercial |
$14.50
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
DENTISTRY, OPERATIVE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
DENTISTRY, OPERATIVE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
Deoxycorticosterone
|
Professional
|
Both
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.36 |
| Max. Negotiated Rate |
$429.40 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.20
|
| Rate for Payer: Health EOS Commercial |
$411.32
|
| Rate for Payer: HFN Commercial |
$429.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.36
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$429.40
|
| Rate for Payer: Quartz Beloit One Network |
$198.88
|
| Rate for Payer: Quartz Commercial |
$257.64
|
| Rate for Payer: The Alliance Commercial |
$226.00
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Deoxycorticosterone
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.98 |
| Max. Negotiated Rate |
$415.84 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Aetna Managed Medicare |
$30.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.43
|
| Rate for Payer: Anthem Medicaid |
$32.01
|
| Rate for Payer: Anthem Medicare Advantage |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.98
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.94
|
| Rate for Payer: Dean Health Medicaid |
$32.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.98
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.98
|
| Rate for Payer: Managed Health Services Medicaid |
$33.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.98
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.47
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32.01
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$293.80
|
| Rate for Payer: Quartz Medicare Advantage |
$30.98
|
| Rate for Payer: The Alliance Commercial |
$123.92
|
| Rate for Payer: United Healthcare Medicaid |
$32.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.98
|
| Rate for Payer: United Healthcare PPO |
$339.00
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: Wellcare Medicare |
$30.98
|
| Rate for Payer: WMAP Medicaid |
$32.01
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Deoxycorticosterone
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
977923
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$221.48 |
| Max. Negotiated Rate |
$415.84 |
| Rate for Payer: Aetna Commercial |
$406.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.56
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$415.84
|
| Rate for Payer: Health EOS Commercial |
$402.28
|
| Rate for Payer: HFN Commercial |
$415.84
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: NAPHCARE Commercial |
$271.20
|
| Rate for Payer: Preferred Network Access Commercial |
$415.84
|
| Rate for Payer: Quartz Beloit One Network |
$221.48
|
| Rate for Payer: Quartz Commercial |
$271.20
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
Depo Suspension 3.75 mg Charge
|
Professional
|
Both
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,061.28 |
| Max. Negotiated Rate |
$3,940.30 |
| Rate for Payer: Aetna Commercial |
$2,291.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,291.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,576.12
|
| Rate for Payer: Health EOS Commercial |
$2,194.92
|
| Rate for Payer: HFN Commercial |
$2,291.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,851.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,851.28
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,291.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,061.28
|
| Rate for Payer: Quartz Commercial |
$1,374.84
|
| Rate for Payer: The Alliance Commercial |
$1,206.00
|
| Rate for Payer: United Healthcare Medicaid |
$1,564.60
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$3,940.30
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
|
OP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,157.76 |
| Max. Negotiated Rate |
$6,258.42 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,564.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,567.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,206.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,157.76
|
| Rate for Payer: Anthem Medicare Advantage |
$1,564.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,564.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,564.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,085.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,564.60
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,820.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,564.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,564.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,564.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,564.60
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,346.91
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,567.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,564.60
|
| Rate for Payer: The Alliance Commercial |
$6,258.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: Wellcare Medicare |
$1,564.60
|
| Rate for Payer: WPS Commercial |
$3,940.30
|
|
|
Depo Suspension 3.75 mg Charge
|
Facility
|
IP
|
$2,412.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
2958934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,181.88 |
| Max. Negotiated Rate |
$2,219.04 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,447.20
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$24,421.00
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$8,784.39 |
| Max. Negotiated Rate |
$24,421.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,784.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,091.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,633.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,902.98
|
| Rate for Payer: Anthem Medicare Advantage |
$8,784.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,784.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,784.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,784.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,433.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,784.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,676.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,784.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,784.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,784.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,784.39
|
| Rate for Payer: NAPHCARE Commercial |
$13,176.58
|
| Rate for Payer: Quartz Medicare Advantage |
$8,784.39
|
| Rate for Payer: The Alliance Commercial |
$24,421.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,784.39
|
| Rate for Payer: United Healthcare PPO |
$13,761.58
|
| Rate for Payer: Wellcare Medicare |
$8,784.39
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
|
OP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,356.88 |
| Max. Negotiated Rate |
$19,384.00 |
| Rate for Payer: Aetna Commercial |
$4,361.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,167.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,356.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,149.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,423.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,326.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,568.38
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,458.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,711.82
|
| Rate for Payer: Health EOS Commercial |
$4,312.94
|
| Rate for Payer: HFN Commercial |
$4,458.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,634.50
|
| Rate for Payer: Multiplan Commercial |
$3,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,907.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,458.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,374.54
|
| Rate for Payer: Quartz Commercial |
$3,149.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,907.60
|
| Rate for Payer: The Alliance Commercial |
$19,384.00
|
| Rate for Payer: WEA Trust Commercial |
$2,665.30
|
| Rate for Payer: WPS Commercial |
$3,589.43
|
|
|
DEPTH GAUGE/COUNTER SINK 3.0MM IS1104
|
Facility
|
IP
|
$4,846.00
|
|
| Hospital Charge Code |
5831690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,374.54 |
| Max. Negotiated Rate |
$4,458.32 |
| Rate for Payer: Aetna Commercial |
$4,361.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,167.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,568.38
|
| Rate for Payer: Cash Price |
$1,453.80
|
| Rate for Payer: Cigna Commercial |
$4,458.32
|
| Rate for Payer: Health EOS Commercial |
$4,312.94
|
| Rate for Payer: HFN Commercial |
$4,458.32
|
| Rate for Payer: Multiplan Commercial |
$3,876.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,907.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,458.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,374.54
|
| Rate for Payer: Quartz Commercial |
$2,907.60
|
| Rate for Payer: WEA Trust Commercial |
$2,665.30
|
| Rate for Payer: WPS Commercial |
$3,589.43
|
|
|
DE QUERVAIN'S RELEASE
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2959994
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
DE QUERVAIN'S RELEASE
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959994
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM CLR222US
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
5349538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$624.26 |
| Max. Negotiated Rate |
$1,172.08 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$764.40
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 22CM CLR222US
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
5349538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$5,096.00 |
| Rate for Payer: Aetna Commercial |
$1,146.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,095.64
|
| Rate for Payer: Aetna Managed Medicare |
$356.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$828.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$637.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$611.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.22
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,172.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$712.93
|
| Rate for Payer: Health EOS Commercial |
$1,133.86
|
| Rate for Payer: HFN Commercial |
$1,172.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$955.50
|
| Rate for Payer: Multiplan Commercial |
$1,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$764.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,172.08
|
| Rate for Payer: Quartz Beloit One Network |
$624.26
|
| Rate for Payer: Quartz Commercial |
$828.10
|
| Rate for Payer: Quartz Medicare Advantage |
$764.40
|
| Rate for Payer: The Alliance Commercial |
$5,096.00
|
| Rate for Payer: WEA Trust Commercial |
$700.70
|
| Rate for Payer: WPS Commercial |
$943.65
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM CLR422US
|
Facility
|
IP
|
$1,634.00
|
|
| Hospital Charge Code |
5384952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$800.66 |
| Max. Negotiated Rate |
$1,503.28 |
| Rate for Payer: Aetna Commercial |
$1,470.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,405.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.02
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,503.28
|
| Rate for Payer: Health EOS Commercial |
$1,454.26
|
| Rate for Payer: HFN Commercial |
$1,503.28
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: NAPHCARE Commercial |
$980.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,503.28
|
| Rate for Payer: Quartz Beloit One Network |
$800.66
|
| Rate for Payer: Quartz Commercial |
$980.40
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
DERMABOND PRINEO SKIN CLOSURE SYSTEM 42CM CLR422US
|
Facility
|
OP
|
$1,634.00
|
|
| Hospital Charge Code |
5384952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$457.52 |
| Max. Negotiated Rate |
$6,536.00 |
| Rate for Payer: Aetna Commercial |
$1,470.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,405.24
|
| Rate for Payer: Aetna Managed Medicare |
$457.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,062.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$817.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$784.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.02
|
| Rate for Payer: Cash Price |
$490.20
|
| Rate for Payer: Cigna Commercial |
$1,503.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$914.39
|
| Rate for Payer: Health EOS Commercial |
$1,454.26
|
| Rate for Payer: HFN Commercial |
$1,503.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,225.50
|
| Rate for Payer: Multiplan Commercial |
$1,307.20
|
| Rate for Payer: NAPHCARE Commercial |
$980.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,503.28
|
| Rate for Payer: Quartz Beloit One Network |
$800.66
|
| Rate for Payer: Quartz Commercial |
$1,062.10
|
| Rate for Payer: Quartz Medicare Advantage |
$980.40
|
| Rate for Payer: The Alliance Commercial |
$6,536.00
|
| Rate for Payer: WEA Trust Commercial |
$898.70
|
| Rate for Payer: WPS Commercial |
$1,210.30
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
|
OP
|
$547.00
|
|
| Hospital Charge Code |
2973470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
|
IP
|
$547.00
|
|
| Hospital Charge Code |
2973470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
Dermabond UD Packet [Med]
|
Facility
|
OP
|
$78.00
|
|
| Hospital Charge Code |
2974927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Dermabond UD Packet [Med]
|
Facility
|
IP
|
$78.00
|
|
| Hospital Charge Code |
2974927
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
