|
HLA-DR/DQ Low Resolution
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4852610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$262.15 |
| Max. Negotiated Rate |
$492.20 |
| Rate for Payer: Aetna Commercial |
$481.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.55
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$492.20
|
| Rate for Payer: Health EOS Commercial |
$476.15
|
| Rate for Payer: HFN Commercial |
$492.20
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: NAPHCARE Commercial |
$321.00
|
| Rate for Payer: Preferred Network Access Commercial |
$492.20
|
| Rate for Payer: Quartz Beloit One Network |
$262.15
|
| Rate for Payer: Quartz Commercial |
$321.00
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
|
HLA-DR/DQ Low Resolution
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4852610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$235.40 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Aetna Commercial |
$508.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$508.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.00
|
| Rate for Payer: Health EOS Commercial |
$486.85
|
| Rate for Payer: HFN Commercial |
$508.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$431.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$431.44
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: Preferred Network Access Commercial |
$508.25
|
| Rate for Payer: Quartz Beloit One Network |
$235.40
|
| Rate for Payer: Quartz Commercial |
$304.95
|
| Rate for Payer: The Alliance Commercial |
$267.50
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
|
HME Filter
|
Facility
|
IP
|
$57.00
|
|
| Hospital Charge Code |
3101739
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$52.44 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$34.20
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$34.20
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
HME Filter
|
Facility
|
OP
|
$57.00
|
|
| Hospital Charge Code |
3101739
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.90
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$34.20
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$37.05
|
| Rate for Payer: Quartz Medicare Advantage |
$34.20
|
| Rate for Payer: The Alliance Commercial |
$228.00
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
HNID
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.43 |
| Max. Negotiated Rate |
$190.44 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$124.20
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$124.20
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
HNID
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$190.44 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Aetna Managed Medicare |
$8.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.41
|
| Rate for Payer: Anthem Medicaid |
$8.35
|
| Rate for Payer: Anthem Medicare Advantage |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.08
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.84
|
| Rate for Payer: Dean Health Medicaid |
$8.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.08
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.08
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.08
|
| Rate for Payer: Managed Health Services Medicaid |
$8.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.08
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$12.12
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.35
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$134.55
|
| Rate for Payer: Quartz Medicare Advantage |
$8.08
|
| Rate for Payer: The Alliance Commercial |
$32.32
|
| Rate for Payer: United Healthcare Medicaid |
$8.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.08
|
| Rate for Payer: United Healthcare PPO |
$155.25
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: Wellcare Medicare |
$8.08
|
| Rate for Payer: WMAP Medicaid |
$8.35
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
HNID
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.52 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$196.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$188.37
|
| Rate for Payer: HFN Commercial |
$196.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$196.65
|
| Rate for Payer: Quartz Beloit One Network |
$91.08
|
| Rate for Payer: Quartz Commercial |
$117.99
|
| Rate for Payer: The Alliance Commercial |
$103.50
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
HOLDER BUNION GREAT TOE
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
2970991
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.20
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
HOLDER BUNION GREAT TOE
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
2970991
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Aetna Managed Medicare |
$3.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.72
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7.20
|
| Rate for Payer: The Alliance Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
HOLDER DRESSING FOOT BAND
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
2970640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$30.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$65.40
|
| Rate for Payer: The Alliance Commercial |
$436.00
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
HOLDER DRESSING FOOT BAND
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
2970640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
HOLDER FOLEY CATHETER LEG BAND DALE HOLD-N-PLACE H8410316
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
2963587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
HOLDER FOLEY CATHETER LEG BAND DALE HOLD-N-PLACE H8410316
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
2963587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
HOLDER LOW EXTREMITY TOE
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2970620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$60.60
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
HOLDER LOW EXTREMITY TOE
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2970620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.28 |
| Max. Negotiated Rate |
$404.00 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Aetna Managed Medicare |
$28.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.52
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.75
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$65.65
|
| Rate for Payer: Quartz Medicare Advantage |
$60.60
|
| Rate for Payer: The Alliance Commercial |
$404.00
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
HOLDER TUBE ENDOTRACHEAL NEONATE GRIP 42-2540
|
Facility
|
OP
|
$222.00
|
|
| Hospital Charge Code |
2973019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.16 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| Rate for Payer: Aetna Managed Medicare |
$62.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.23
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.50
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$144.30
|
| Rate for Payer: Quartz Medicare Advantage |
$133.20
|
| Rate for Payer: The Alliance Commercial |
$888.00
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
HOLDER TUBE ENDOTRACHEAL NEONATE GRIP 42-2540
|
Facility
|
IP
|
$222.00
|
|
| Hospital Charge Code |
2973019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.78 |
| Max. Negotiated Rate |
$204.24 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$133.20
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
HOLE ELIMINATOR APEX PS 1246-03-000
|
Facility
|
OP
|
$2,157.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$603.96 |
| Max. Negotiated Rate |
$8,628.00 |
| Rate for Payer: Aetna Commercial |
$1,941.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,855.02
|
| Rate for Payer: Aetna Managed Medicare |
$603.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,402.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,078.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,035.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,143.21
|
| Rate for Payer: Cash Price |
$647.10
|
| Rate for Payer: Cigna Commercial |
$1,984.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,207.06
|
| Rate for Payer: Health EOS Commercial |
$1,919.73
|
| Rate for Payer: HFN Commercial |
$1,984.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,617.75
|
| Rate for Payer: Multiplan Commercial |
$1,725.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,294.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,984.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,056.93
|
| Rate for Payer: Quartz Commercial |
$1,402.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,294.20
|
| Rate for Payer: The Alliance Commercial |
$8,628.00
|
| Rate for Payer: WEA Trust Commercial |
$1,186.35
|
| Rate for Payer: WPS Commercial |
$1,597.69
|
|
|
HOLE ELIMINATOR APEX PS 1246-03-000
|
Facility
|
IP
|
$2,157.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459305
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,056.93 |
| Max. Negotiated Rate |
$1,984.44 |
| Rate for Payer: Aetna Commercial |
$1,941.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,855.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,143.21
|
| Rate for Payer: Cash Price |
$647.10
|
| Rate for Payer: Cigna Commercial |
$1,984.44
|
| Rate for Payer: Health EOS Commercial |
$1,919.73
|
| Rate for Payer: HFN Commercial |
$1,984.44
|
| Rate for Payer: Multiplan Commercial |
$1,725.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,294.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,984.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,056.93
|
| Rate for Payer: Quartz Commercial |
$1,294.20
|
| Rate for Payer: WEA Trust Commercial |
$1,186.35
|
| Rate for Payer: WPS Commercial |
$1,597.69
|
|
|
Holter Monitor 24 hr
|
Professional
|
Both
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$66.51 |
| Max. Negotiated Rate |
$792.30 |
| Rate for Payer: Aetna Commercial |
$792.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$717.24
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$792.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$417.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.40
|
| Rate for Payer: Health EOS Commercial |
$758.94
|
| Rate for Payer: HFN Commercial |
$792.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.51
|
| Rate for Payer: Multiplan Commercial |
$667.20
|
| Rate for Payer: Preferred Network Access Commercial |
$792.30
|
| Rate for Payer: Quartz Beloit One Network |
$366.96
|
| Rate for Payer: Quartz Commercial |
$475.38
|
| Rate for Payer: The Alliance Commercial |
$417.00
|
| Rate for Payer: WEA Trust Commercial |
$458.70
|
| Rate for Payer: WPS Commercial |
$617.74
|
|
|
Holter Monitor 24 hr
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$408.66 |
| Max. Negotiated Rate |
$767.28 |
| Rate for Payer: Aetna Commercial |
$750.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$717.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$442.02
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$767.28
|
| Rate for Payer: Health EOS Commercial |
$742.26
|
| Rate for Payer: HFN Commercial |
$767.28
|
| Rate for Payer: Multiplan Commercial |
$667.20
|
| Rate for Payer: NAPHCARE Commercial |
$500.40
|
| Rate for Payer: Preferred Network Access Commercial |
$767.28
|
| Rate for Payer: Quartz Beloit One Network |
$408.66
|
| Rate for Payer: Quartz Commercial |
$500.40
|
| Rate for Payer: WEA Trust Commercial |
$458.70
|
| Rate for Payer: WPS Commercial |
$617.74
|
|
|
Holter Monitor 24 hr
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$767.28 |
| Rate for Payer: Aetna Commercial |
$750.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$717.24
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$542.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$417.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$400.32
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$442.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$767.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$466.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$742.26
|
| Rate for Payer: HFN Commercial |
$767.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$667.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$767.28
|
| Rate for Payer: Quartz Beloit One Network |
$408.66
|
| Rate for Payer: Quartz Commercial |
$542.10
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$625.50
|
| Rate for Payer: WEA Trust Commercial |
$458.70
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$617.74
|
|
|
Holter Monitor 48 hr
|
Facility
|
OP
|
$1,666.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382945
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$1,532.72 |
| Rate for Payer: Aetna Commercial |
$1,499.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.76
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,082.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$833.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$799.68
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$882.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,532.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$932.29
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$1,482.74
|
| Rate for Payer: HFN Commercial |
$1,532.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$1,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.72
|
| Rate for Payer: Quartz Beloit One Network |
$816.34
|
| Rate for Payer: Quartz Commercial |
$1,082.90
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$1,249.50
|
| Rate for Payer: WEA Trust Commercial |
$916.30
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$1,234.01
|
|
|
Holter Monitor 48 hr
|
Professional
|
Both
|
$1,666.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382945
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$66.51 |
| Max. Negotiated Rate |
$1,582.70 |
| Rate for Payer: Aetna Commercial |
$1,582.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.76
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,582.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$833.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$999.60
|
| Rate for Payer: Health EOS Commercial |
$1,516.06
|
| Rate for Payer: HFN Commercial |
$1,582.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.51
|
| Rate for Payer: Multiplan Commercial |
$1,332.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,582.70
|
| Rate for Payer: Quartz Beloit One Network |
$733.04
|
| Rate for Payer: Quartz Commercial |
$949.62
|
| Rate for Payer: The Alliance Commercial |
$833.00
|
| Rate for Payer: WEA Trust Commercial |
$916.30
|
| Rate for Payer: WPS Commercial |
$1,234.01
|
|
|
Holter Monitor 48 hr
|
Facility
|
IP
|
$1,666.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382945
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$816.34 |
| Max. Negotiated Rate |
$1,532.72 |
| Rate for Payer: Aetna Commercial |
$1,499.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$882.98
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,532.72
|
| Rate for Payer: Health EOS Commercial |
$1,482.74
|
| Rate for Payer: HFN Commercial |
$1,532.72
|
| Rate for Payer: Multiplan Commercial |
$1,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$999.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.72
|
| Rate for Payer: Quartz Beloit One Network |
$816.34
|
| Rate for Payer: Quartz Commercial |
$999.60
|
| Rate for Payer: WEA Trust Commercial |
$916.30
|
| Rate for Payer: WPS Commercial |
$1,234.01
|
|
