|
FOLLOWER 12FR HEYMAN 021312
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Aetna Managed Medicare |
$159.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.35
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.66
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: NAPHCARE Commercial |
$341.33
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$369.77
|
| Rate for Payer: Quartz Medicare Advantage |
$341.33
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
FOLLOWER 14FR HEYMAN 021314
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$289.45 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$354.43
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
FOLLOWER 14FR HEYMAN 021314
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$165.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$383.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$283.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.58
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$443.04
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$354.43
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$383.97
|
| Rate for Payer: Quartz Medicare Advantage |
$354.43
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
FOLLOWER 16FR HEYMAN 021316
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.75 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$341.33
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
FOLLOWER 16FR HEYMAN 021316
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Aetna Managed Medicare |
$159.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.35
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.66
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: NAPHCARE Commercial |
$341.33
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$369.77
|
| Rate for Payer: Quartz Medicare Advantage |
$341.33
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
FOLLOWER 18FR HEYMAN 021318
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.46 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$322.61
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
FOLLOWER 18FR HEYMAN 021318
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Aetna Managed Medicare |
$150.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$258.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.89
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.26
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: NAPHCARE Commercial |
$322.61
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$349.49
|
| Rate for Payer: Quartz Medicare Advantage |
$322.61
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
FOLLOWER 20FR HEYMAN 021320
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
FOLLOWER 20FR HEYMAN 021320
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
FOLLOWER 22FR HEYMAN 021322
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Aetna Managed Medicare |
$73.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$170.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.66
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.56
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: NAPHCARE Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$170.35
|
| Rate for Payer: Quartz Medicare Advantage |
$157.25
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
FOLLOWER 22FR HEYMAN 021322
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$128.42 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$235.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.90
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$241.11
|
| Rate for Payer: Health EOS Commercial |
$233.25
|
| Rate for Payer: HFN Commercial |
$241.11
|
| Rate for Payer: Multiplan Commercial |
$209.66
|
| Rate for Payer: Preferred Network Access Commercial |
$241.11
|
| Rate for Payer: Quartz Beloit One Network |
$128.42
|
| Rate for Payer: Quartz Commercial |
$157.25
|
| Rate for Payer: WEA Trust Commercial |
$144.14
|
| Rate for Payer: WPS Commercial |
$194.12
|
|
|
FOLLOWER 24FR HEYMAN 021324
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
FOLLOWER 24FR HEYMAN 021324
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
FOLLOWUP EVAL OF FOOT PT LOP G0246
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
HCPCS G0246
|
| Hospital Charge Code |
5381863
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.49 |
| Max. Negotiated Rate |
$144.25 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.58
|
| Rate for Payer: Aetna Managed Medicare |
$17.49
|
| Rate for Payer: Anthem Medicare Advantage |
$17.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.49
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$144.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.49
|
| Rate for Payer: Health EOS Commercial |
$138.17
|
| Rate for Payer: HFN Commercial |
$144.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.49
|
| Rate for Payer: Multiplan Commercial |
$121.47
|
| Rate for Payer: NAPHCARE Commercial |
$26.24
|
| Rate for Payer: Preferred Network Access Commercial |
$144.25
|
| Rate for Payer: Quartz Beloit One Network |
$66.81
|
| Rate for Payer: Quartz Commercial |
$86.55
|
| Rate for Payer: Quartz Medicare Advantage |
$17.49
|
| Rate for Payer: The Alliance Commercial |
$48.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.49
|
| Rate for Payer: WEA Trust Commercial |
$83.51
|
| Rate for Payer: WPS Commercial |
$30.61
|
|
|
FOLOTYN 1 mg Charge
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$16.85
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
FOLOTYN 1 mg Charge
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$1,633.72 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$408.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.48
|
| Rate for Payer: Anthem Medicare Advantage |
$408.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$408.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$408.43
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$408.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$411.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$408.43
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,519.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$408.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$408.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$408.43
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$612.64
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$18.25
|
| Rate for Payer: Quartz Medicare Advantage |
$408.43
|
| Rate for Payer: The Alliance Commercial |
$1,633.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$408.43
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: Wellcare Medicare |
$408.43
|
| Rate for Payer: WPS Commercial |
$778.13
|
|
|
FOLOTYN 1 mg Charge
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.36 |
| Max. Negotiated Rate |
$1,123.18 |
| Rate for Payer: Aetna Commercial |
$26.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$408.43
|
| Rate for Payer: Anthem Medicare Advantage |
$408.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$408.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$408.43
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$408.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.25
|
| Rate for Payer: Health EOS Commercial |
$25.55
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$472.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$472.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$408.43
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$612.64
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$12.36
|
| Rate for Payer: Quartz Commercial |
$16.01
|
| Rate for Payer: Quartz Medicare Advantage |
$408.43
|
| Rate for Payer: The Alliance Commercial |
$1,123.18
|
| Rate for Payer: United Healthcare Medicaid |
$408.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$408.43
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$778.13
|
|
|
FO nontorsion joint CF L3935
|
Professional
|
Both
|
$710.00
|
|
|
Service Code
|
HCPCS L3935
|
| Hospital Charge Code |
3206212
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$256.95 |
| Max. Negotiated Rate |
$740.92 |
| Rate for Payer: Aetna Commercial |
$701.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.02
|
| Rate for Payer: Aetna Managed Medicare |
$256.95
|
| Rate for Payer: Anthem Medicare Advantage |
$256.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$256.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$256.95
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$701.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$369.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.95
|
| Rate for Payer: Health EOS Commercial |
$671.94
|
| Rate for Payer: HFN Commercial |
$701.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$740.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$740.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$256.95
|
| Rate for Payer: Multiplan Commercial |
$590.72
|
| Rate for Payer: NAPHCARE Commercial |
$385.43
|
| Rate for Payer: Preferred Network Access Commercial |
$701.48
|
| Rate for Payer: Quartz Beloit One Network |
$324.90
|
| Rate for Payer: Quartz Commercial |
$420.89
|
| Rate for Payer: Quartz Medicare Advantage |
$256.95
|
| Rate for Payer: The Alliance Commercial |
$706.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$256.95
|
| Rate for Payer: WEA Trust Commercial |
$406.12
|
| Rate for Payer: WPS Commercial |
$449.67
|
|
|
FO nontorsion joint CF L3935
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
HCPCS L3935
|
| Hospital Charge Code |
3206212
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$82.25 |
| Max. Negotiated Rate |
$1,027.81 |
| Rate for Payer: Aetna Commercial |
$664.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.02
|
| Rate for Payer: Aetna Managed Medicare |
$206.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$82.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$391.35
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$679.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$413.22
|
| Rate for Payer: Health EOS Commercial |
$657.18
|
| Rate for Payer: HFN Commercial |
$679.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$553.80
|
| Rate for Payer: Multiplan Commercial |
$590.72
|
| Rate for Payer: NAPHCARE Commercial |
$443.04
|
| Rate for Payer: Preferred Network Access Commercial |
$679.33
|
| Rate for Payer: Quartz Beloit One Network |
$361.82
|
| Rate for Payer: Quartz Commercial |
$479.96
|
| Rate for Payer: Quartz Medicare Advantage |
$443.04
|
| Rate for Payer: The Alliance Commercial |
$1,027.81
|
| Rate for Payer: WEA Trust Commercial |
$406.12
|
| Rate for Payer: WPS Commercial |
$546.91
|
|
|
FO nontorsion joint CF L3935
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
HCPCS L3935
|
| Hospital Charge Code |
3206212
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$361.82 |
| Max. Negotiated Rate |
$679.33 |
| Rate for Payer: Aetna Commercial |
$664.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$635.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$391.35
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$679.33
|
| Rate for Payer: Health EOS Commercial |
$657.18
|
| Rate for Payer: HFN Commercial |
$679.33
|
| Rate for Payer: Multiplan Commercial |
$590.72
|
| Rate for Payer: Preferred Network Access Commercial |
$679.33
|
| Rate for Payer: Quartz Beloit One Network |
$361.82
|
| Rate for Payer: Quartz Commercial |
$443.04
|
| Rate for Payer: WEA Trust Commercial |
$406.12
|
| Rate for Payer: WPS Commercial |
$546.91
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$8,592.94
|
|
|
Service Code
|
APR-DRG 3141
|
| Min. Negotiated Rate |
$7,632.79 |
| Max. Negotiated Rate |
$8,592.94 |
| Rate for Payer: Anthem Medicaid |
$8,228.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,228.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,228.22
|
| Rate for Payer: Dean Health Medicaid |
$8,228.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,632.79
|
| Rate for Payer: Managed Health Services Medicaid |
$8,592.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,228.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,228.22
|
| Rate for Payer: United Healthcare Medicaid |
$8,228.22
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$17,098.20
|
|
|
Service Code
|
APR-DRG 3143
|
| Min. Negotiated Rate |
$15,187.69 |
| Max. Negotiated Rate |
$17,098.20 |
| Rate for Payer: Anthem Medicaid |
$16,372.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,372.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,372.47
|
| Rate for Payer: Dean Health Medicaid |
$16,372.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,187.69
|
| Rate for Payer: Managed Health Services Medicaid |
$17,098.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,372.47
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,372.47
|
| Rate for Payer: United Healthcare Medicaid |
$16,372.47
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$11,398.80
|
|
|
Service Code
|
APR-DRG 3142
|
| Min. Negotiated Rate |
$10,125.13 |
| Max. Negotiated Rate |
$11,398.80 |
| Rate for Payer: Anthem Medicaid |
$10,914.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,914.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,914.98
|
| Rate for Payer: Dean Health Medicaid |
$10,914.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,125.13
|
| Rate for Payer: Managed Health Services Medicaid |
$11,398.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,914.98
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,914.98
|
| Rate for Payer: United Healthcare Medicaid |
$10,914.98
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$27,444.81
|
|
|
Service Code
|
APR-DRG 3144
|
| Min. Negotiated Rate |
$24,378.19 |
| Max. Negotiated Rate |
$27,444.81 |
| Rate for Payer: Anthem Medicaid |
$26,279.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26,279.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26,279.92
|
| Rate for Payer: Dean Health Medicaid |
$26,279.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24,378.19
|
| Rate for Payer: Managed Health Services Medicaid |
$27,444.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,279.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26,279.92
|
| Rate for Payer: United Healthcare Medicaid |
$26,279.92
|
|
|
Foot Arch Support Adult, pair L3050
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
HCPCS L3050
|
| Hospital Charge Code |
5544796
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$240.61 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$48.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.78
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.04
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$104.83
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: Quartz Medicare Advantage |
$104.83
|
| Rate for Payer: The Alliance Commercial |
$240.61
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
