|
EXTENDER TIGHTROPE BUTTON AR-1589RT
|
Facility
|
OP
|
$2,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$670.32 |
| Max. Negotiated Rate |
$9,576.00 |
| Rate for Payer: Aetna Commercial |
$2,154.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.84
|
| Rate for Payer: Aetna Managed Medicare |
$670.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.82
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cigna Commercial |
$2,202.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.68
|
| Rate for Payer: Health EOS Commercial |
$2,130.66
|
| Rate for Payer: HFN Commercial |
$2,202.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,795.50
|
| Rate for Payer: Multiplan Commercial |
$1,915.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,436.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.06
|
| Rate for Payer: Quartz Commercial |
$1,556.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,436.40
|
| Rate for Payer: The Alliance Commercial |
$9,576.00
|
| Rate for Payer: WEA Trust Commercial |
$1,316.70
|
| Rate for Payer: WPS Commercial |
$1,773.24
|
|
|
EXTENSION LINE HPT200E
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2972326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$28.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$61.20
|
| Rate for Payer: The Alliance Commercial |
$408.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
EXTENSION LINE HPT200E
|
Facility
|
IP
|
$102.00
|
|
| Hospital Charge Code |
2972326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
EXTENSION SET FILTER 1.2 MICRON 12354-05
|
Facility
|
IP
|
$110.00
|
|
| Hospital Charge Code |
4494206
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
EXTENSION SET FILTER 1.2 MICRON 12354-05
|
Facility
|
OP
|
$110.00
|
|
| Hospital Charge Code |
4494206
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Aetna Managed Medicare |
$30.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.56
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.50
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$71.50
|
| Rate for Payer: Quartz Medicare Advantage |
$66.00
|
| Rate for Payer: The Alliance Commercial |
$440.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Extension Tubing
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
3040293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Extension Tubing
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
3040293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Extension tubing with stopcock - Peripheral IV Equipment:
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
3003558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
Extension tubing with stopcock - Peripheral IV Equipment:
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
3003558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$80,929.00
|
|
|
Service Code
|
MSDRG 933
|
| Min. Negotiated Rate |
$29,111.18 |
| Max. Negotiated Rate |
$80,929.00 |
| Rate for Payer: Aetna Managed Medicare |
$29,111.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63,569.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48,725.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46,292.34
|
| Rate for Payer: Anthem Medicare Advantage |
$29,111.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29,111.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29,111.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29,111.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51,388.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29,111.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59,124.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29,111.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29,111.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29,111.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29,111.18
|
| Rate for Payer: NAPHCARE Commercial |
$43,666.77
|
| Rate for Payer: Quartz Medicare Advantage |
$29,111.18
|
| Rate for Payer: The Alliance Commercial |
$80,929.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29,111.18
|
| Rate for Payer: United Healthcare PPO |
$46,028.79
|
| Rate for Payer: Wellcare Medicare |
$29,111.18
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT
|
Facility
|
IP
|
$701,092.00
|
|
|
Service Code
|
MSDRG 927
|
| Min. Negotiated Rate |
$252,191.28 |
| Max. Negotiated Rate |
$701,092.00 |
| Rate for Payer: Aetna Managed Medicare |
$252,191.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$553,032.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$423,895.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$402,728.08
|
| Rate for Payer: Anthem Medicare Advantage |
$252,191.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$252,191.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$252,191.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$252,191.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$447,065.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$252,191.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$513,994.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252,191.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$252,191.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$252,191.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$252,191.28
|
| Rate for Payer: NAPHCARE Commercial |
$378,286.92
|
| Rate for Payer: Quartz Medicare Advantage |
$252,191.28
|
| Rate for Payer: The Alliance Commercial |
$701,092.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$252,191.28
|
| Rate for Payer: United Healthcare PPO |
$400,151.42
|
| Rate for Payer: Wellcare Medicare |
$252,191.28
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$66,413.00
|
|
|
Service Code
|
MSDRG 982
|
| Min. Negotiated Rate |
$23,889.62 |
| Max. Negotiated Rate |
$66,413.00 |
| Rate for Payer: Aetna Managed Medicare |
$23,889.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52,240.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40,041.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38,042.22
|
| Rate for Payer: Anthem Medicare Advantage |
$23,889.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23,889.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23,889.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23,889.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42,230.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23,889.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48,477.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23,889.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23,889.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23,889.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23,889.62
|
| Rate for Payer: NAPHCARE Commercial |
$35,834.43
|
| Rate for Payer: Quartz Medicare Advantage |
$23,889.62
|
| Rate for Payer: The Alliance Commercial |
$66,413.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,889.62
|
| Rate for Payer: United Healthcare PPO |
$37,739.97
|
| Rate for Payer: Wellcare Medicare |
$23,889.62
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$126,349.00
|
|
|
Service Code
|
MSDRG 981
|
| Min. Negotiated Rate |
$45,449.11 |
| Max. Negotiated Rate |
$126,349.00 |
| Rate for Payer: Aetna Managed Medicare |
$45,449.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99,445.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76,223.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72,417.72
|
| Rate for Payer: Anthem Medicare Advantage |
$45,449.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45,449.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45,449.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$45,449.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80,390.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$45,449.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92,437.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45,449.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45,449.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$45,449.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$45,449.11
|
| Rate for Payer: NAPHCARE Commercial |
$68,173.66
|
| Rate for Payer: Quartz Medicare Advantage |
$45,449.11
|
| Rate for Payer: The Alliance Commercial |
$126,349.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45,449.11
|
| Rate for Payer: United Healthcare PPO |
$71,964.01
|
| Rate for Payer: Wellcare Medicare |
$45,449.11
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$43,794.00
|
|
|
Service Code
|
MSDRG 983
|
| Min. Negotiated Rate |
$15,753.16 |
| Max. Negotiated Rate |
$43,794.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,753.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,407.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,372.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,055.92
|
| Rate for Payer: Anthem Medicare Advantage |
$15,753.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,753.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,753.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,753.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,814.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,753.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,886.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,753.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,753.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,753.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,753.16
|
| Rate for Payer: NAPHCARE Commercial |
$23,629.74
|
| Rate for Payer: Quartz Medicare Advantage |
$15,753.16
|
| Rate for Payer: The Alliance Commercial |
$43,794.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,753.16
|
| Rate for Payer: United Healthcare PPO |
$24,823.97
|
| Rate for Payer: Wellcare Medicare |
$15,753.16
|
|
|
EXTENSOR/FLEXOR TENDON REPAIR
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2960414
|
|
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
|
|
|
EXTENSOR/FLEXOR TENDON REPAIR
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2960414
|
|
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
|
|
|
EXTENTION HOSE WITH CONNECTOR TOURNIQUET DUAL STERILE 60-1812-101-00
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
5729897
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.04 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$157.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
EXTENTION HOSE WITH CONNECTOR TOURNIQUET DUAL STERILE 60-1812-101-00
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
5729897
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
EXTERNAL ECG REC>48HR<7D RECORDING- 93242
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
5727950
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
EXTERNAL ECG REC>48HR<7D RECORDING- 93242
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
5727950
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$158.56 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.00
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: The Alliance Commercial |
$158.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
EXTERNAL ECG REC>7D<15D RECORDING- 93246
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
5727949
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$158.56 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.00
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$65.00
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: The Alliance Commercial |
$158.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
EXTERNAL ECG REC>7D<15D RECORDING- 93246
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
5727949
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$92.00
|
| Rate for Payer: Health EOS Commercial |
$89.00
|
| Rate for Payer: HFN Commercial |
$92.00
|
| Rate for Payer: Multiplan Commercial |
$80.00
|
| Rate for Payer: NAPHCARE Commercial |
$60.00
|
| Rate for Payer: Preferred Network Access Commercial |
$92.00
|
| Rate for Payer: Quartz Beloit One Network |
$49.00
|
| Rate for Payer: Quartz Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$55.00
|
| Rate for Payer: WPS Commercial |
$74.07
|
|
|
EXTERNAL NEUROSTIMULATOR INTERSTIM 353101
|
Facility
|
OP
|
$4,871.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
5349490
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,363.88 |
| Max. Negotiated Rate |
$19,484.00 |
| Rate for Payer: Aetna Commercial |
$4,383.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,189.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,363.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,166.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,435.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,338.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,581.63
|
| Rate for Payer: Cash Price |
$1,461.30
|
| Rate for Payer: Cigna Commercial |
$4,481.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,725.81
|
| Rate for Payer: Health EOS Commercial |
$4,335.19
|
| Rate for Payer: HFN Commercial |
$4,481.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,653.25
|
| Rate for Payer: Multiplan Commercial |
$3,896.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,922.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,481.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,386.79
|
| Rate for Payer: Quartz Commercial |
$3,166.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,922.60
|
| Rate for Payer: The Alliance Commercial |
$19,484.00
|
| Rate for Payer: WEA Trust Commercial |
$2,679.05
|
| Rate for Payer: WPS Commercial |
$3,607.95
|
|
|
EXTERNAL NEUROSTIMULATOR INTERSTIM 353101
|
Facility
|
IP
|
$4,871.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
5349490
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,386.79 |
| Max. Negotiated Rate |
$4,481.32 |
| Rate for Payer: Aetna Commercial |
$4,383.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,189.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,581.63
|
| Rate for Payer: Cash Price |
$1,461.30
|
| Rate for Payer: Cigna Commercial |
$4,481.32
|
| Rate for Payer: Health EOS Commercial |
$4,335.19
|
| Rate for Payer: HFN Commercial |
$4,481.32
|
| Rate for Payer: Multiplan Commercial |
$3,896.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,922.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,481.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,386.79
|
| Rate for Payer: Quartz Commercial |
$2,922.60
|
| Rate for Payer: WEA Trust Commercial |
$2,679.05
|
| Rate for Payer: WPS Commercial |
$3,607.95
|
|
|
External Pacemaker
|
Facility
|
IP
|
$814.00
|
|
| Hospital Charge Code |
3052550
|
|
Hospital Revenue Code
|
230
|
| Min. Negotiated Rate |
$398.86 |
| Max. Negotiated Rate |
$748.88 |
| Rate for Payer: Aetna Commercial |
$732.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$700.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$431.42
|
| Rate for Payer: Cash Price |
$244.20
|
| Rate for Payer: Cigna Commercial |
$748.88
|
| Rate for Payer: Health EOS Commercial |
$724.46
|
| Rate for Payer: HFN Commercial |
$748.88
|
| Rate for Payer: Multiplan Commercial |
$651.20
|
| Rate for Payer: NAPHCARE Commercial |
$488.40
|
| Rate for Payer: Preferred Network Access Commercial |
$748.88
|
| Rate for Payer: Quartz Beloit One Network |
$398.86
|
| Rate for Payer: Quartz Commercial |
$488.40
|
| Rate for Payer: WEA Trust Commercial |
$447.70
|
| Rate for Payer: WPS Commercial |
$602.93
|
|
