|
17-Hydroxyprogesterone
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
977764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.26 |
| Max. Negotiated Rate |
$410.02 |
| Rate for Payer: Aetna Commercial |
$410.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Aetna Managed Medicare |
$28.26
|
| Rate for Payer: Anthem Medicare Advantage |
$28.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.26
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$410.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.26
|
| Rate for Payer: Health EOS Commercial |
$392.76
|
| Rate for Payer: HFN Commercial |
$410.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.26
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: NAPHCARE Commercial |
$42.39
|
| Rate for Payer: Preferred Network Access Commercial |
$410.02
|
| Rate for Payer: Quartz Beloit One Network |
$189.90
|
| Rate for Payer: Quartz Commercial |
$246.01
|
| Rate for Payer: Quartz Medicare Advantage |
$28.26
|
| Rate for Payer: The Alliance Commercial |
$111.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.26
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$124.33
|
|
|
17-Hydroxyprogesterone
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
977764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$211.48 |
| Max. Negotiated Rate |
$397.07 |
| Rate for Payer: Aetna Commercial |
$388.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.75
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$397.07
|
| Rate for Payer: Health EOS Commercial |
$384.12
|
| Rate for Payer: HFN Commercial |
$397.07
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: Preferred Network Access Commercial |
$397.07
|
| Rate for Payer: Quartz Beloit One Network |
$211.48
|
| Rate for Payer: Quartz Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
17-Ketosteroids
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.98 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$128.54
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
17-Ketosteroids
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.31 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Aetna Managed Medicare |
$13.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.10
|
| Rate for Payer: Anthem Medicare Advantage |
$13.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.31
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.31
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.31
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$139.26
|
| Rate for Payer: Quartz Medicare Advantage |
$13.31
|
| Rate for Payer: The Alliance Commercial |
$53.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.31
|
| Rate for Payer: United Healthcare PPO |
$160.68
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: Wellcare Medicare |
$13.31
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
17-Ketosteroids
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
CPT 83586
|
| Hospital Charge Code |
1037503
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.31 |
| Max. Negotiated Rate |
$203.53 |
| Rate for Payer: Aetna Commercial |
$203.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Aetna Managed Medicare |
$13.31
|
| Rate for Payer: Anthem Medicare Advantage |
$13.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.31
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$203.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.31
|
| Rate for Payer: Health EOS Commercial |
$194.96
|
| Rate for Payer: HFN Commercial |
$203.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.31
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$203.53
|
| Rate for Payer: Quartz Beloit One Network |
$94.27
|
| Rate for Payer: Quartz Commercial |
$122.12
|
| Rate for Payer: Quartz Medicare Advantage |
$13.31
|
| Rate for Payer: The Alliance Commercial |
$52.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.31
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$58.57
|
|
|
18 - Catheter size
|
Facility
|
IP
|
$97.00
|
|
| Hospital Charge Code |
2999974
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.43 |
| Max. Negotiated Rate |
$92.81 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$60.53
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
18 - Catheter size
|
Facility
|
OP
|
$97.00
|
|
| Hospital Charge Code |
2999974
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$92.81 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Aetna Managed Medicare |
$28.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.45
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.66
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: NAPHCARE Commercial |
$60.53
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$65.57
|
| Rate for Payer: Quartz Medicare Advantage |
$60.53
|
| Rate for Payer: The Alliance Commercial |
$50.44
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
18Fr Esophageal Stethtemp
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
3101743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
18Fr Esophageal Stethtemp
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
3101743
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
1 hour - Respiratory Therapy Treatment Duration
|
Facility
|
IP
|
$516.00
|
|
| Hospital Charge Code |
3023876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$262.95 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$321.98
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
1 hour - Respiratory Therapy Treatment Duration
|
Facility
|
OP
|
$516.00
|
|
| Hospital Charge Code |
3023876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$150.26 |
| Max. Negotiated Rate |
$493.71 |
| Rate for Payer: Aetna Commercial |
$482.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$461.51
|
| Rate for Payer: Aetna Managed Medicare |
$150.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$348.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$257.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.42
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cigna Commercial |
$493.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.31
|
| Rate for Payer: Health EOS Commercial |
$477.61
|
| Rate for Payer: HFN Commercial |
$493.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$402.48
|
| Rate for Payer: Multiplan Commercial |
$429.31
|
| Rate for Payer: NAPHCARE Commercial |
$321.98
|
| Rate for Payer: Preferred Network Access Commercial |
$493.71
|
| Rate for Payer: Quartz Beloit One Network |
$262.95
|
| Rate for Payer: Quartz Commercial |
$348.82
|
| Rate for Payer: Quartz Medicare Advantage |
$321.98
|
| Rate for Payer: The Alliance Commercial |
$268.32
|
| Rate for Payer: WEA Trust Commercial |
$295.15
|
| Rate for Payer: WPS Commercial |
$397.47
|
|
|
2000745- Ostomy scissors
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
5375211
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$106.70
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
2000745- Ostomy scissors
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
5375211
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Aetna Managed Medicare |
$49.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.52
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.38
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: NAPHCARE Commercial |
$106.70
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$115.60
|
| Rate for Payer: Quartz Medicare Advantage |
$106.70
|
| Rate for Payer: The Alliance Commercial |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
2000751- Ostomy clamps
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
5375212
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$11.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.20
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$24.96
|
| Rate for Payer: The Alliance Commercial |
$20.80
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
2000751- Ostomy clamps
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
5375212
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
2000752- Ostomy belt
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS A4367
|
| Hospital Charge Code |
5375229
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.35 |
| Max. Negotiated Rate |
$135.87 |
| Rate for Payer: Aetna Commercial |
$132.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.00
|
| Rate for Payer: Aetna Managed Medicare |
$41.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.27
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$135.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.64
|
| Rate for Payer: Health EOS Commercial |
$131.44
|
| Rate for Payer: HFN Commercial |
$135.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.76
|
| Rate for Payer: Multiplan Commercial |
$118.14
|
| Rate for Payer: NAPHCARE Commercial |
$88.61
|
| Rate for Payer: Preferred Network Access Commercial |
$135.87
|
| Rate for Payer: Quartz Beloit One Network |
$72.36
|
| Rate for Payer: Quartz Commercial |
$95.99
|
| Rate for Payer: Quartz Medicare Advantage |
$88.61
|
| Rate for Payer: The Alliance Commercial |
$43.64
|
| Rate for Payer: WEA Trust Commercial |
$81.22
|
| Rate for Payer: WPS Commercial |
$109.38
|
|
|
2000752- Ostomy belt
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS A4367
|
| Hospital Charge Code |
5375229
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$72.36 |
| Max. Negotiated Rate |
$135.87 |
| Rate for Payer: Aetna Commercial |
$132.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.27
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$135.87
|
| Rate for Payer: Health EOS Commercial |
$131.44
|
| Rate for Payer: HFN Commercial |
$135.87
|
| Rate for Payer: Multiplan Commercial |
$118.14
|
| Rate for Payer: Preferred Network Access Commercial |
$135.87
|
| Rate for Payer: Quartz Beloit One Network |
$72.36
|
| Rate for Payer: Quartz Commercial |
$88.61
|
| Rate for Payer: WEA Trust Commercial |
$81.22
|
| Rate for Payer: WPS Commercial |
$109.38
|
|
|
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 |
$16.31 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$19.97
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
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 |
$9.32 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$21.63
|
| Rate for Payer: Quartz Medicare Advantage |
$19.97
|
| Rate for Payer: The Alliance Commercial |
$16.06
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
2000755- 1 3/4 Wafer- 2 pc app
|
Facility
|
OP
|
$61.00
|
|
| Hospital Charge Code |
5375216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.58
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
2000755- 1 3/4 Wafer- 2 pc app
|
Facility
|
IP
|
$61.00
|
|
| Hospital Charge Code |
5375216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
2000757- 1 3/4 Urostomy- 2 pc app
|
Facility
|
OP
|
$55.00
|
|
| Hospital Charge Code |
5375223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.02 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$16.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.01
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.90
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$34.32
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$34.32
|
| Rate for Payer: The Alliance Commercial |
$28.60
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
2000757- 1 3/4 Urostomy- 2 pc app
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
5375223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
2000765- One piece appliance- Open end
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
5375213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.68
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.78
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$31.82
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$34.48
|
| Rate for Payer: Quartz Medicare Advantage |
$31.82
|
| Rate for Payer: The Alliance Commercial |
$26.52
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
|
2000765- One piece appliance- Open end
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
5375213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.80 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.11
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.80
|
| Rate for Payer: Health EOS Commercial |
$47.21
|
| Rate for Payer: HFN Commercial |
$48.80
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: Preferred Network Access Commercial |
$48.80
|
| Rate for Payer: Quartz Beloit One Network |
$25.99
|
| Rate for Payer: Quartz Commercial |
$31.82
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.29
|
|
