|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 56MM 6942-5-056
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 57MM 6942-5-057
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 57MM 6942-5-057
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519607
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 58MM 6942-5-058
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 58MM 6942-5-058
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 59MM 6942-5-059
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 59MM 6942-5-059
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519606
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 60MM 6942-5-060
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4519605
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 60MM 6942-5-060
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4519605
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 61MM 6942-5-061
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 61MM 6942-5-061
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEADGEAR INFANT LARGE 777040L
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2974777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
HEADGEAR INFANT LARGE 777040L
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2974777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
HEADGEAR INFANT MED 777040ML
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2974778
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
HEADGEAR INFANT MED 777040ML
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2974778
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
HEAD MODULAR HUMERAL
|
Facility
|
OP
|
$9,561.00
|
|
| Hospital Charge Code |
2967490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,784.16 |
| Max. Negotiated Rate |
$9,147.96 |
| Rate for Payer: Aetna Commercial |
$8,949.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,551.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,784.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,463.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,971.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,772.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,270.02
|
| Rate for Payer: Cash Price |
$2,868.30
|
| Rate for Payer: Cigna Commercial |
$9,147.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,564.50
|
| Rate for Payer: Health EOS Commercial |
$8,849.66
|
| Rate for Payer: HFN Commercial |
$9,147.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,457.58
|
| Rate for Payer: Multiplan Commercial |
$7,954.75
|
| Rate for Payer: NAPHCARE Commercial |
$5,966.06
|
| Rate for Payer: Preferred Network Access Commercial |
$9,147.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,872.29
|
| Rate for Payer: Quartz Commercial |
$6,463.24
|
| Rate for Payer: Quartz Medicare Advantage |
$5,966.06
|
| Rate for Payer: The Alliance Commercial |
$4,971.72
|
| Rate for Payer: WEA Trust Commercial |
$5,468.89
|
| Rate for Payer: WPS Commercial |
$7,364.84
|
|
|
HEAD MODULAR HUMERAL
|
Facility
|
IP
|
$9,561.00
|
|
| Hospital Charge Code |
2967490
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.29 |
| Max. Negotiated Rate |
$9,147.96 |
| Rate for Payer: Aetna Commercial |
$8,949.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,551.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,270.02
|
| Rate for Payer: Cash Price |
$2,868.30
|
| Rate for Payer: Cigna Commercial |
$9,147.96
|
| Rate for Payer: Health EOS Commercial |
$8,849.66
|
| Rate for Payer: HFN Commercial |
$9,147.96
|
| Rate for Payer: Multiplan Commercial |
$7,954.75
|
| Rate for Payer: Preferred Network Access Commercial |
$9,147.96
|
| Rate for Payer: Quartz Beloit One Network |
$4,872.29
|
| Rate for Payer: Quartz Commercial |
$5,966.06
|
| Rate for Payer: WEA Trust Commercial |
$5,468.89
|
| Rate for Payer: WPS Commercial |
$7,364.84
|
|
|
HEAD & NECK TUMOR RESECTION/RECONSTRUCTION
|
Facility
|
IP
|
$4,048.00
|
|
| Hospital Charge Code |
2950500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,062.86 |
| Max. Negotiated Rate |
$3,873.13 |
| Rate for Payer: Aetna Commercial |
$3,788.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,620.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,231.26
|
| Rate for Payer: Cash Price |
$1,214.40
|
| Rate for Payer: Cigna Commercial |
$3,873.13
|
| Rate for Payer: Health EOS Commercial |
$3,746.83
|
| Rate for Payer: HFN Commercial |
$3,873.13
|
| Rate for Payer: Multiplan Commercial |
$3,367.94
|
| Rate for Payer: Preferred Network Access Commercial |
$3,873.13
|
| Rate for Payer: Quartz Beloit One Network |
$2,062.86
|
| Rate for Payer: Quartz Commercial |
$2,525.95
|
| Rate for Payer: WEA Trust Commercial |
$2,315.46
|
| Rate for Payer: WPS Commercial |
$3,118.17
|
|
|
HEAD & NECK TUMOR RESECTION/RECONSTRUCTION
|
Facility
|
OP
|
$4,048.00
|
|
| Hospital Charge Code |
2950500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,178.78 |
| Max. Negotiated Rate |
$3,873.13 |
| Rate for Payer: Aetna Commercial |
$3,788.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,620.53
|
| Rate for Payer: Aetna Managed Medicare |
$1,178.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,736.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,104.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,020.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,231.26
|
| Rate for Payer: Cash Price |
$1,214.40
|
| Rate for Payer: Cigna Commercial |
$3,873.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,355.94
|
| Rate for Payer: Health EOS Commercial |
$3,746.83
|
| Rate for Payer: HFN Commercial |
$3,873.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,157.44
|
| Rate for Payer: Multiplan Commercial |
$3,367.94
|
| Rate for Payer: NAPHCARE Commercial |
$2,525.95
|
| Rate for Payer: Preferred Network Access Commercial |
$3,873.13
|
| Rate for Payer: Quartz Beloit One Network |
$2,062.86
|
| Rate for Payer: Quartz Commercial |
$2,736.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,525.95
|
| Rate for Payer: The Alliance Commercial |
$2,104.96
|
| Rate for Payer: WEA Trust Commercial |
$2,315.46
|
| Rate for Payer: WPS Commercial |
$3,118.17
|
|
|
HEAD RESTRAINT ALLEN UNIVERSAL A-90023
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
5106864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.79 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$278.93
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
HEAD RESTRAINT ALLEN UNIVERSAL A-90023
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
5106864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.17 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Aetna Managed Medicare |
$130.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.15
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.66
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: NAPHCARE Commercial |
$278.93
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$302.17
|
| Rate for Payer: Quartz Medicare Advantage |
$278.93
|
| Rate for Payer: The Alliance Commercial |
$232.44
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
HEAD TRAUMA
|
Facility
|
OP
|
$96.96
|
|
|
Service Code
|
EAPG 00532
|
| Min. Negotiated Rate |
$93.23 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Anthem Medicaid |
$93.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$93.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.23
|
| Rate for Payer: Dean Health Medicaid |
$93.23
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$93.23
|
| Rate for Payer: Managed Health Services Medicaid |
$96.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.23
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$93.23
|
| Rate for Payer: United Healthcare Medicaid |
$93.23
|
|
|
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE
|
Facility
|
IP
|
$24,288.22
|
|
|
Service Code
|
APR-DRG 0554
|
| Min. Negotiated Rate |
$21,574.31 |
| Max. Negotiated Rate |
$24,288.22 |
| Rate for Payer: Anthem Medicaid |
$23,257.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$23,257.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23,257.31
|
| Rate for Payer: Dean Health Medicaid |
$23,257.31
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,574.31
|
| Rate for Payer: Managed Health Services Medicaid |
$24,288.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,257.31
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23,257.31
|
| Rate for Payer: United Healthcare Medicaid |
$23,257.31
|
|
|
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE
|
Facility
|
IP
|
$9,031.36
|
|
|
Service Code
|
APR-DRG 0552
|
| Min. Negotiated Rate |
$8,022.22 |
| Max. Negotiated Rate |
$9,031.36 |
| Rate for Payer: Anthem Medicaid |
$8,648.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,648.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,648.02
|
| Rate for Payer: Dean Health Medicaid |
$8,648.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,022.22
|
| Rate for Payer: Managed Health Services Medicaid |
$9,031.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,648.02
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,648.02
|
| Rate for Payer: United Healthcare Medicaid |
$8,648.02
|
|
|
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE
|
Facility
|
IP
|
$6,488.55
|
|
|
Service Code
|
APR-DRG 0551
|
| Min. Negotiated Rate |
$5,763.53 |
| Max. Negotiated Rate |
$6,488.55 |
| Rate for Payer: Anthem Medicaid |
$6,213.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,213.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,213.14
|
| Rate for Payer: Dean Health Medicaid |
$6,213.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,763.53
|
| Rate for Payer: Managed Health Services Medicaid |
$6,488.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,213.14
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,213.14
|
| Rate for Payer: United Healthcare Medicaid |
$6,213.14
|
|
