|
DORSAL BLOCKING SPLINT SMALL
|
Facility
|
IP
|
$769.00
|
|
| Hospital Charge Code |
2971619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$376.81 |
| Max. Negotiated Rate |
$707.48 |
| Rate for Payer: Aetna Commercial |
$692.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.57
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$707.48
|
| Rate for Payer: Health EOS Commercial |
$684.41
|
| Rate for Payer: HFN Commercial |
$707.48
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: NAPHCARE Commercial |
$461.40
|
| Rate for Payer: Preferred Network Access Commercial |
$707.48
|
| Rate for Payer: Quartz Beloit One Network |
$376.81
|
| Rate for Payer: Quartz Commercial |
$461.40
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
|
DORSAL SLIT
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959997
|
|
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
|
|
|
DORSAL SLIT
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959997
|
|
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
|
|
|
Dorzolamide Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2974995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$133.40 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
Dorzolamide Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2974995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$580.00 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.70
|
| Rate for Payer: Aetna Managed Medicare |
$40.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.85
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$133.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.14
|
| Rate for Payer: Health EOS Commercial |
$129.05
|
| Rate for Payer: HFN Commercial |
$133.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.75
|
| Rate for Payer: Multiplan Commercial |
$116.00
|
| Rate for Payer: NAPHCARE Commercial |
$87.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.40
|
| Rate for Payer: Quartz Beloit One Network |
$71.05
|
| Rate for Payer: Quartz Commercial |
$94.25
|
| Rate for Payer: Quartz Medicare Advantage |
$87.00
|
| Rate for Payer: The Alliance Commercial |
$580.00
|
| Rate for Payer: WEA Trust Commercial |
$79.75
|
| Rate for Payer: WPS Commercial |
$107.40
|
|
|
Dosimetry Plan, Total Body 7732126
|
Professional
|
Both
|
$681.00
|
|
|
Service Code
|
CPT 77321 26
|
| Hospital Charge Code |
5258632
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.84 |
| Max. Negotiated Rate |
$646.95 |
| Rate for Payer: Aetna Commercial |
$646.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$585.66
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cigna Commercial |
$646.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$340.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$408.60
|
| Rate for Payer: Health EOS Commercial |
$619.71
|
| Rate for Payer: HFN Commercial |
$646.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.84
|
| Rate for Payer: Multiplan Commercial |
$544.80
|
| Rate for Payer: Preferred Network Access Commercial |
$646.95
|
| Rate for Payer: Quartz Beloit One Network |
$299.64
|
| Rate for Payer: Quartz Commercial |
$388.17
|
| Rate for Payer: The Alliance Commercial |
$340.50
|
| Rate for Payer: WEA Trust Commercial |
$374.55
|
| Rate for Payer: WPS Commercial |
$504.42
|
|
|
Dotatate
|
Facility
|
OP
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,338.16 |
| Max. Negotiated Rate |
$47,688.00 |
| Rate for Payer: Aetna Commercial |
$10,729.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,252.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,338.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,749.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,961.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,722.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,318.66
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$10,968.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,671.55
|
| Rate for Payer: Health EOS Commercial |
$10,610.58
|
| Rate for Payer: HFN Commercial |
$10,968.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,941.50
|
| Rate for Payer: Multiplan Commercial |
$9,537.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,153.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,968.24
|
| Rate for Payer: Quartz Beloit One Network |
$5,841.78
|
| Rate for Payer: Quartz Commercial |
$7,749.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,153.20
|
| Rate for Payer: The Alliance Commercial |
$47,688.00
|
| Rate for Payer: WEA Trust Commercial |
$6,557.10
|
| Rate for Payer: WPS Commercial |
$8,830.63
|
|
|
Dotatate
|
Facility
|
IP
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,841.78 |
| Max. Negotiated Rate |
$10,968.24 |
| Rate for Payer: Aetna Commercial |
$10,729.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,252.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,318.66
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$10,968.24
|
| Rate for Payer: Health EOS Commercial |
$10,610.58
|
| Rate for Payer: HFN Commercial |
$10,968.24
|
| Rate for Payer: Multiplan Commercial |
$9,537.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,153.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,968.24
|
| Rate for Payer: Quartz Beloit One Network |
$5,841.78
|
| Rate for Payer: Quartz Commercial |
$7,153.20
|
| Rate for Payer: WEA Trust Commercial |
$6,557.10
|
| Rate for Payer: WPS Commercial |
$8,830.63
|
|
|
Dotatate
|
Professional
|
Both
|
$11,922.00
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
5454948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.56 |
| Max. Negotiated Rate |
$11,325.90 |
| Rate for Payer: Aetna Commercial |
$11,325.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,252.92
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cash Price |
$3,576.60
|
| Rate for Payer: Cigna Commercial |
$11,325.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,961.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,153.20
|
| Rate for Payer: Health EOS Commercial |
$10,849.02
|
| Rate for Payer: HFN Commercial |
$11,325.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.56
|
| Rate for Payer: Multiplan Commercial |
$9,537.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,325.90
|
| Rate for Payer: Quartz Beloit One Network |
$5,245.68
|
| Rate for Payer: Quartz Commercial |
$6,795.54
|
| Rate for Payer: The Alliance Commercial |
$5,961.00
|
| Rate for Payer: WEA Trust Commercial |
$6,557.10
|
| Rate for Payer: WPS Commercial |
$8,830.63
|
|
|
DOUBLE CUT 4.0MM X 13CM AR-8400DC
|
Facility
|
IP
|
$925.00
|
|
| Hospital Charge Code |
5106647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$453.25 |
| Max. Negotiated Rate |
$851.00 |
| Rate for Payer: Aetna Commercial |
$832.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$795.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.25
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$851.00
|
| Rate for Payer: Health EOS Commercial |
$823.25
|
| Rate for Payer: HFN Commercial |
$851.00
|
| Rate for Payer: Multiplan Commercial |
$740.00
|
| Rate for Payer: NAPHCARE Commercial |
$555.00
|
| Rate for Payer: Preferred Network Access Commercial |
$851.00
|
| Rate for Payer: Quartz Beloit One Network |
$453.25
|
| Rate for Payer: Quartz Commercial |
$555.00
|
| Rate for Payer: WEA Trust Commercial |
$508.75
|
| Rate for Payer: WPS Commercial |
$685.15
|
|
|
DOUBLE CUT 4.0MM X 13CM AR-8400DC
|
Facility
|
OP
|
$925.00
|
|
| Hospital Charge Code |
5106647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$259.00 |
| Max. Negotiated Rate |
$3,700.00 |
| Rate for Payer: Aetna Commercial |
$832.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$795.50
|
| Rate for Payer: Aetna Managed Medicare |
$259.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$601.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$462.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$444.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.25
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$851.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$517.63
|
| Rate for Payer: Health EOS Commercial |
$823.25
|
| Rate for Payer: HFN Commercial |
$851.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$693.75
|
| Rate for Payer: Multiplan Commercial |
$740.00
|
| Rate for Payer: NAPHCARE Commercial |
$555.00
|
| Rate for Payer: Preferred Network Access Commercial |
$851.00
|
| Rate for Payer: Quartz Beloit One Network |
$453.25
|
| Rate for Payer: Quartz Commercial |
$601.25
|
| Rate for Payer: Quartz Medicare Advantage |
$555.00
|
| Rate for Payer: The Alliance Commercial |
$3,700.00
|
| Rate for Payer: WEA Trust Commercial |
$508.75
|
| Rate for Payer: WPS Commercial |
$685.15
|
|
|
Doxepin Lvl / 826
|
Professional
|
Both
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$214.70 |
| Rate for Payer: Aetna Commercial |
$214.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$194.36
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$214.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.60
|
| Rate for Payer: Health EOS Commercial |
$205.66
|
| Rate for Payer: HFN Commercial |
$214.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$180.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.70
|
| Rate for Payer: Quartz Beloit One Network |
$99.44
|
| Rate for Payer: Quartz Commercial |
$128.82
|
| Rate for Payer: The Alliance Commercial |
$113.00
|
| Rate for Payer: WEA Trust Commercial |
$124.30
|
| Rate for Payer: WPS Commercial |
$167.40
|
|
|
Doxepin Lvl / 826
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$904.00 |
| Rate for Payer: Aetna Commercial |
$203.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$194.36
|
| Rate for Payer: Aetna Managed Medicare |
$63.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$146.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$113.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.78
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$207.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.47
|
| Rate for Payer: Health EOS Commercial |
$201.14
|
| Rate for Payer: HFN Commercial |
$207.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.50
|
| Rate for Payer: Multiplan Commercial |
$180.80
|
| Rate for Payer: NAPHCARE Commercial |
$135.60
|
| Rate for Payer: Preferred Network Access Commercial |
$207.92
|
| Rate for Payer: Quartz Beloit One Network |
$110.74
|
| Rate for Payer: Quartz Commercial |
$146.90
|
| Rate for Payer: Quartz Medicare Advantage |
$135.60
|
| Rate for Payer: The Alliance Commercial |
$904.00
|
| Rate for Payer: United Healthcare PPO |
$169.50
|
| Rate for Payer: WEA Trust Commercial |
$124.30
|
| Rate for Payer: WPS Commercial |
$167.40
|
|
|
Doxepin Lvl / 826
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.74 |
| Max. Negotiated Rate |
$207.92 |
| Rate for Payer: Aetna Commercial |
$203.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$194.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.78
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cigna Commercial |
$207.92
|
| Rate for Payer: Health EOS Commercial |
$201.14
|
| Rate for Payer: HFN Commercial |
$207.92
|
| Rate for Payer: Multiplan Commercial |
$180.80
|
| Rate for Payer: NAPHCARE Commercial |
$135.60
|
| Rate for Payer: Preferred Network Access Commercial |
$207.92
|
| Rate for Payer: Quartz Beloit One Network |
$110.74
|
| Rate for Payer: Quartz Commercial |
$135.60
|
| Rate for Payer: WEA Trust Commercial |
$124.30
|
| Rate for Payer: WPS Commercial |
$167.40
|
|
|
DRAIN 15FR HUBLESS 3/4 FLUTED SILICONE CHANNEL 072228
|
Facility
|
IP
|
$234.00
|
|
| Hospital Charge Code |
5729793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
DRAIN 15FR HUBLESS 3/4 FLUTED SILICONE CHANNEL 072228
|
Facility
|
OP
|
$234.00
|
|
| Hospital Charge Code |
5729793
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$152.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$112.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.50
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
DRAIN 24FR HUBLESS FULL-FLUTED 072234
|
Facility
|
OP
|
$400.00
|
|
| Hospital Charge Code |
2964765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$360.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.00
|
| Rate for Payer: Aetna Managed Medicare |
$112.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$368.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$223.84
|
| Rate for Payer: Health EOS Commercial |
$356.00
|
| Rate for Payer: HFN Commercial |
$368.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$300.00
|
| Rate for Payer: Multiplan Commercial |
$320.00
|
| Rate for Payer: NAPHCARE Commercial |
$240.00
|
| Rate for Payer: Preferred Network Access Commercial |
$368.00
|
| Rate for Payer: Quartz Beloit One Network |
$196.00
|
| Rate for Payer: Quartz Commercial |
$260.00
|
| Rate for Payer: Quartz Medicare Advantage |
$240.00
|
| Rate for Payer: The Alliance Commercial |
$1,600.00
|
| Rate for Payer: WEA Trust Commercial |
$220.00
|
| Rate for Payer: WPS Commercial |
$296.28
|
|
|
DRAIN 24FR HUBLESS FULL-FLUTED 072234
|
Facility
|
IP
|
$400.00
|
|
| Hospital Charge Code |
2964765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.00 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$360.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$368.00
|
| Rate for Payer: Health EOS Commercial |
$356.00
|
| Rate for Payer: HFN Commercial |
$368.00
|
| Rate for Payer: Multiplan Commercial |
$320.00
|
| Rate for Payer: NAPHCARE Commercial |
$240.00
|
| Rate for Payer: Preferred Network Access Commercial |
$368.00
|
| Rate for Payer: Quartz Beloit One Network |
$196.00
|
| Rate for Payer: Quartz Commercial |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$220.00
|
| Rate for Payer: WPS Commercial |
$296.28
|
|
|
DRAINABLE POUCH CUT TO FIT
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
2974465
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Aetna Managed Medicare |
$19.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.61
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.75
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$44.85
|
| Rate for Payer: Quartz Medicare Advantage |
$41.40
|
| Rate for Payer: The Alliance Commercial |
$276.00
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
DRAINABLE POUCH CUT TO FIT
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
2974465
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$63.48 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$41.40
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
Drainage Bag
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
1158862
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Drainage Bag
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
1158862
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Drainage Bag
|
Professional
|
Both
|
$138.00
|
|
| Hospital Charge Code |
1158862
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$60.72 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Drainage External Auditory Canal, Abscess
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
CPT 69020
|
| Hospital Charge Code |
1190824
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.11 |
| Max. Negotiated Rate |
$479.23 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$365.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.00
|
| Rate for Payer: Health EOS Commercial |
$350.35
|
| Rate for Payer: HFN Commercial |
$365.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$479.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$479.23
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: Preferred Network Access Commercial |
$365.75
|
| Rate for Payer: Quartz Beloit One Network |
$169.40
|
| Rate for Payer: Quartz Commercial |
$219.45
|
| Rate for Payer: The Alliance Commercial |
$192.50
|
| Rate for Payer: United Healthcare Medicaid |
$30.11
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Drainage External Ear Abscess Or Hematoma; Complicated
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
CPT 69005
|
| Hospital Charge Code |
1190823
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.16 |
| Max. Negotiated Rate |
$526.82 |
| Rate for Payer: Aetna Commercial |
$427.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$387.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$427.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.00
|
| Rate for Payer: Health EOS Commercial |
$409.50
|
| Rate for Payer: HFN Commercial |
$427.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$526.82
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$427.50
|
| Rate for Payer: Quartz Beloit One Network |
$198.00
|
| Rate for Payer: Quartz Commercial |
$256.50
|
| Rate for Payer: The Alliance Commercial |
$225.00
|
| Rate for Payer: United Healthcare Medicaid |
$71.16
|
| Rate for Payer: WEA Trust Commercial |
$247.50
|
| Rate for Payer: WPS Commercial |
$333.32
|
|
