|
17-Hydroxyprogesterone
|
Facility
OP
|
$415.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
977764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$1,660.00 |
| Rate for Payer: Aetna Commercial |
$373.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.90
|
| Rate for Payer: Aetna Managed Medicare |
$27.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.10
|
| Rate for Payer: Anthem Medicaid |
$28.07
|
| Rate for Payer: Anthem Medicare Advantage |
$27.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.17
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.07
|
| Rate for Payer: Dean Health Medicaid |
$28.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27.17
|
| Rate for Payer: Health EOS Commercial |
$369.35
|
| Rate for Payer: HFN Commercial |
$381.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$28.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.17
|
| Rate for Payer: Managed Health Services Medicaid |
$29.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27.17
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: NAPHCARE Commercial |
$40.76
|
| Rate for Payer: Preferred Network Access Commercial |
$381.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28.07
|
| Rate for Payer: Quartz Beloit One Network |
$203.35
|
| Rate for Payer: Quartz Commercial |
$269.75
|
| Rate for Payer: Quartz Medicare Advantage |
$27.17
|
| Rate for Payer: The Alliance Commercial |
$1,660.00
|
| Rate for Payer: United Healthcare Medicaid |
$28.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.17
|
| Rate for Payer: United Healthcare PPO |
$311.25
|
| Rate for Payer: WEA Trust Commercial |
$228.25
|
| Rate for Payer: Wellcare Medicare |
$27.17
|
| Rate for Payer: WMAP Medicaid |
$28.07
|
| Rate for Payer: WPS Commercial |
$307.39
|
|
|
17-Hydroxyprogesterone
|
Facility
IP
|
$415.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
977764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$203.35 |
| Max. Negotiated Rate |
$381.80 |
| Rate for Payer: Aetna Commercial |
$373.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.95
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: Health EOS Commercial |
$369.35
|
| Rate for Payer: HFN Commercial |
$381.80
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: NAPHCARE Commercial |
$249.00
|
| Rate for Payer: Preferred Network Access Commercial |
$381.80
|
| Rate for Payer: Quartz Beloit One Network |
$203.35
|
| Rate for Payer: Quartz Commercial |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$228.25
|
| Rate for Payer: WPS Commercial |
$307.39
|
|
|
17-Ketosteroids
|
Facility
OP
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$824.00 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Aetna Managed Medicare |
$12.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.25
|
| Rate for Payer: Anthem Medicaid |
$13.23
|
| Rate for Payer: Anthem Medicare Advantage |
$12.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.23
|
| Rate for Payer: Dean Health Medicaid |
$13.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.80
|
| Rate for Payer: Managed Health Services Medicaid |
$13.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.80
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.23
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$133.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12.80
|
| Rate for Payer: The Alliance Commercial |
$824.00
|
| Rate for Payer: United Healthcare Medicaid |
$13.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.80
|
| Rate for Payer: United Healthcare PPO |
$154.50
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: Wellcare Medicare |
$12.80
|
| Rate for Payer: WMAP Medicaid |
$13.23
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
17-Ketosteroids
|
Facility
IP
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.94 |
| Max. Negotiated Rate |
$189.52 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$123.60
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$123.60
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
17-Ketosteroids
|
Professional
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Aetna Managed Medicare |
$12.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$187.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.80
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.70
|
| Rate for Payer: Quartz Beloit One Network |
$90.64
|
| Rate for Payer: Quartz Commercial |
$117.42
|
| Rate for Payer: Quartz Medicare Advantage |
$12.80
|
| Rate for Payer: The Alliance Commercial |
$50.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.80
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$56.32
|
|
|
18 - Catheter size
|
Facility
OP
|
$97.00
|
|
| Hospital Charge Code |
2999974
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.16 |
| Max. Negotiated Rate |
$388.00 |
| Rate for Payer: Aetna Commercial |
$87.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Aetna Managed Medicare |
$27.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.41
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$89.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$86.33
|
| Rate for Payer: HFN Commercial |
$89.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.75
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: NAPHCARE Commercial |
$58.20
|
| Rate for Payer: Preferred Network Access Commercial |
$89.24
|
| Rate for Payer: Quartz Beloit One Network |
$47.53
|
| Rate for Payer: Quartz Commercial |
$63.05
|
| Rate for Payer: Quartz Medicare Advantage |
$58.20
|
| Rate for Payer: The Alliance Commercial |
$388.00
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
18 - Catheter size
|
Facility
IP
|
$97.00
|
|
| Hospital Charge Code |
2999974
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.53 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Aetna Commercial |
$87.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.41
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$89.24
|
| Rate for Payer: Health EOS Commercial |
$86.33
|
| Rate for Payer: HFN Commercial |
$89.24
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: NAPHCARE Commercial |
$58.20
|
| Rate for Payer: Preferred Network Access Commercial |
$89.24
|
| Rate for Payer: Quartz Beloit One Network |
$47.53
|
| Rate for Payer: Quartz Commercial |
$58.20
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
18Fr Esophageal Stethtemp
|
Facility
OP
|
$72.00
|
|
| Hospital Charge Code |
3101743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.29
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$43.20
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
18Fr Esophageal Stethtemp
|
Facility
IP
|
$72.00
|
|
| Hospital Charge Code |
3101743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
1 hour - Respiratory Therapy Treatment Duration
|
Facility
OP
|
$516.00
|
|
| Hospital Charge Code |
3023876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$144.48 |
| Max. Negotiated Rate |
$2,064.00 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.76
|
| Rate for Payer: Aetna Managed Medicare |
$144.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.75
|
| Rate for Payer: Health EOS Commercial |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$387.00
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$335.40
|
| Rate for Payer: Quartz Medicare Advantage |
$309.60
|
| Rate for Payer: The Alliance Commercial |
$2,064.00
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
1 hour - Respiratory Therapy Treatment Duration
|
Facility
IP
|
$516.00
|
|
| Hospital Charge Code |
3023876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$252.84 |
| Max. Negotiated Rate |
$474.72 |
| Rate for Payer: Aetna Commercial |
$464.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.48
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$474.72
|
| Rate for Payer: Health EOS Commercial |
$459.24
|
| Rate for Payer: HFN Commercial |
$474.72
|
| Rate for Payer: Multiplan Commercial |
$412.80
|
| Rate for Payer: NAPHCARE Commercial |
$309.60
|
| Rate for Payer: Preferred Network Access Commercial |
$474.72
|
| Rate for Payer: Quartz Beloit One Network |
$252.84
|
| Rate for Payer: Quartz Commercial |
$309.60
|
| Rate for Payer: WEA Trust Commercial |
$283.80
|
| Rate for Payer: WPS Commercial |
$382.20
|
|
|
2000745- Ostomy scissors
|
Facility
IP
|
$171.00
|
|
| Hospital Charge Code |
5375211
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$157.32 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$102.60
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
2000745- Ostomy scissors
|
Facility
OP
|
$171.00
|
|
| Hospital Charge Code |
5375211
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Aetna Managed Medicare |
$47.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.69
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.25
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$111.15
|
| Rate for Payer: Quartz Medicare Advantage |
$102.60
|
| Rate for Payer: The Alliance Commercial |
$684.00
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
2000751- Ostomy clamps
|
Facility
OP
|
$40.00
|
|
| Hospital Charge Code |
5375212
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Aetna Managed Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$26.00
|
| Rate for Payer: Quartz Medicare Advantage |
$24.00
|
| Rate for Payer: The Alliance Commercial |
$160.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
2000751- Ostomy clamps
|
Facility
IP
|
$40.00
|
|
| Hospital Charge Code |
5375212
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
2000752- Ostomy belt
|
Facility
OP
|
$142.00
|
|
|
Service Code
|
HCPCS A4367
|
| Hospital Charge Code |
5375229
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.76 |
| Max. Negotiated Rate |
$130.64 |
| Rate for Payer: Aetna Commercial |
$127.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.12
|
| Rate for Payer: Aetna Managed Medicare |
$39.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$92.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.26
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.46
|
| Rate for Payer: Health EOS Commercial |
$126.38
|
| Rate for Payer: HFN Commercial |
$130.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.50
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: NAPHCARE Commercial |
$85.20
|
| Rate for Payer: Preferred Network Access Commercial |
$130.64
|
| Rate for Payer: Quartz Beloit One Network |
$69.58
|
| Rate for Payer: Quartz Commercial |
$92.30
|
| Rate for Payer: Quartz Medicare Advantage |
$85.20
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
2000752- Ostomy belt
|
Facility
IP
|
$142.00
|
|
|
Service Code
|
HCPCS A4367
|
| Hospital Charge Code |
5375229
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$69.58 |
| Max. Negotiated Rate |
$130.64 |
| Rate for Payer: Aetna Commercial |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.26
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$130.64
|
| Rate for Payer: Health EOS Commercial |
$126.38
|
| Rate for Payer: HFN Commercial |
$130.64
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: NAPHCARE Commercial |
$85.20
|
| Rate for Payer: Preferred Network Access Commercial |
$130.64
|
| Rate for Payer: Quartz Beloit One Network |
$69.58
|
| Rate for Payer: Quartz Commercial |
$85.20
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
2000753- 1 3/4 Pouch- 2 pc app
|
Facility
IP
|
$32.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
5375215
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$19.20
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
2000753- 1 3/4 Pouch- 2 pc app
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
HCPCS A5063
|
| Hospital Charge Code |
5375215
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.91
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$20.80
|
| Rate for Payer: Quartz Medicare Advantage |
$19.20
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
2000755- 1 3/4 Wafer- 2 pc app
|
Facility
OP
|
$61.00
|
|
| Hospital Charge Code |
5375216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$244.00 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
2000755- 1 3/4 Wafer- 2 pc app
|
Facility
IP
|
$61.00
|
|
| Hospital Charge Code |
5375216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
2000757- 1 3/4 Urostomy- 2 pc app
|
Facility
IP
|
$55.00
|
|
| Hospital Charge Code |
5375223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
2000757- 1 3/4 Urostomy- 2 pc app
|
Facility
OP
|
$55.00
|
|
| Hospital Charge Code |
5375223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.78
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$33.00
|
| Rate for Payer: The Alliance Commercial |
$220.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
2000765- One piece appliance- Open end
|
Facility
IP
|
$51.00
|
|
| Hospital Charge Code |
5375213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
2000765- One piece appliance- Open end
|
Facility
OP
|
$51.00
|
|
| Hospital Charge Code |
5375213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$14.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$30.60
|
| Rate for Payer: The Alliance Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
