|
HLA DQB1
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 81382
|
| Hospital Charge Code |
5438973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
HLA-DR/DQ Low Resolution
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4852610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$272.64 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
HLA-DR/DQ Low Resolution
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4852610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.11 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$127.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$476.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$222.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$211.00
|
| Rate for Payer: Anthem Medicare Advantage |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.11
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$127.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$127.11
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$472.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$127.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$127.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$127.11
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$190.66
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$361.66
|
| Rate for Payer: Quartz Medicare Advantage |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$508.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.11
|
| Rate for Payer: United Healthcare PPO |
$417.30
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: Wellcare Medicare |
$127.11
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
HLA-DR/DQ Low Resolution
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
CPT 81376
|
| Hospital Charge Code |
4852610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.11 |
| Max. Negotiated Rate |
$559.28 |
| Rate for Payer: Aetna Commercial |
$528.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$127.11
|
| Rate for Payer: Anthem Medicare Advantage |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.11
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$528.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.11
|
| Rate for Payer: Health EOS Commercial |
$506.32
|
| Rate for Payer: HFN Commercial |
$528.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.11
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$190.66
|
| Rate for Payer: Preferred Network Access Commercial |
$528.58
|
| Rate for Payer: Quartz Beloit One Network |
$244.82
|
| Rate for Payer: Quartz Commercial |
$317.15
|
| Rate for Payer: Quartz Medicare Advantage |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$502.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.11
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$559.28
|
|
|
HME Filter
|
Facility
|
OP
|
$57.00
|
|
| Hospital Charge Code |
3101739
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.60 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Aetna Managed Medicare |
$16.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.17
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.46
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: NAPHCARE Commercial |
$35.57
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$38.53
|
| Rate for Payer: Quartz Medicare Advantage |
$35.57
|
| Rate for Payer: The Alliance Commercial |
$29.64
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
|
HME Filter
|
Facility
|
IP
|
$57.00
|
|
| Hospital Charge Code |
3101739
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.05 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$35.57
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
|
HNID
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$204.52 |
| Rate for Payer: Aetna Commercial |
$204.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Medicare Advantage |
$8.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.40
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$204.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.40
|
| Rate for Payer: Health EOS Commercial |
$195.90
|
| Rate for Payer: HFN Commercial |
$204.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$204.52
|
| Rate for Payer: Quartz Beloit One Network |
$94.72
|
| Rate for Payer: Quartz Commercial |
$122.71
|
| Rate for Payer: Quartz Medicare Advantage |
$8.40
|
| Rate for Payer: The Alliance Commercial |
$33.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.40
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
HNID
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$105.49 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$129.17
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
HNID
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
1942803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.95
|
| Rate for Payer: Anthem Medicare Advantage |
$8.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.40
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.40
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$139.93
|
| Rate for Payer: Quartz Medicare Advantage |
$8.40
|
| Rate for Payer: The Alliance Commercial |
$33.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.40
|
| Rate for Payer: United Healthcare PPO |
$161.46
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: Wellcare Medicare |
$8.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
HOLDER BUNION GREAT TOE
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
2970991
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.61
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.48
|
| Rate for Payer: Health EOS Commercial |
$11.11
|
| Rate for Payer: HFN Commercial |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11.48
|
| Rate for Payer: Quartz Beloit One Network |
$6.12
|
| Rate for Payer: Quartz Commercial |
$7.49
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
HOLDER BUNION GREAT TOE
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
2970991
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Aetna Managed Medicare |
$3.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.61
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.98
|
| Rate for Payer: Health EOS Commercial |
$11.11
|
| Rate for Payer: HFN Commercial |
$11.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: NAPHCARE Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$11.48
|
| Rate for Payer: Quartz Beloit One Network |
$6.12
|
| Rate for Payer: Quartz Commercial |
$8.11
|
| Rate for Payer: Quartz Medicare Advantage |
$7.49
|
| Rate for Payer: The Alliance Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
HOLDER DRESSING FOOT BAND
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
2970640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.55 |
| Max. Negotiated Rate |
$104.29 |
| Rate for Payer: Aetna Commercial |
$102.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.08
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$104.29
|
| Rate for Payer: Health EOS Commercial |
$100.89
|
| Rate for Payer: HFN Commercial |
$104.29
|
| Rate for Payer: Multiplan Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$104.29
|
| Rate for Payer: Quartz Beloit One Network |
$55.55
|
| Rate for Payer: Quartz Commercial |
$68.02
|
| Rate for Payer: WEA Trust Commercial |
$62.35
|
| Rate for Payer: WPS Commercial |
$83.96
|
|
|
HOLDER DRESSING FOOT BAND
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
2970640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.74 |
| Max. Negotiated Rate |
$104.29 |
| Rate for Payer: Aetna Commercial |
$102.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.49
|
| Rate for Payer: Aetna Managed Medicare |
$31.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.08
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$104.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.44
|
| Rate for Payer: Health EOS Commercial |
$100.89
|
| Rate for Payer: HFN Commercial |
$104.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.02
|
| Rate for Payer: Multiplan Commercial |
$90.69
|
| Rate for Payer: NAPHCARE Commercial |
$68.02
|
| Rate for Payer: Preferred Network Access Commercial |
$104.29
|
| Rate for Payer: Quartz Beloit One Network |
$55.55
|
| Rate for Payer: Quartz Commercial |
$73.68
|
| Rate for Payer: Quartz Medicare Advantage |
$68.02
|
| Rate for Payer: The Alliance Commercial |
$56.68
|
| Rate for Payer: WEA Trust Commercial |
$62.35
|
| Rate for Payer: WPS Commercial |
$83.96
|
|
|
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 |
$33.20 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
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 |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
HOLDER LOW EXTREMITY TOE
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2970620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
HOLDER LOW EXTREMITY TOE
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2970620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
HOLDER TUBE ENDOTRACHEAL NEONATE GRIP 42-2540
|
Facility
|
IP
|
$222.00
|
|
| Hospital Charge Code |
2973019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.13 |
| Max. Negotiated Rate |
$212.41 |
| Rate for Payer: Aetna Commercial |
$207.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.37
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$212.41
|
| Rate for Payer: Health EOS Commercial |
$205.48
|
| Rate for Payer: HFN Commercial |
$212.41
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: Preferred Network Access Commercial |
$212.41
|
| Rate for Payer: Quartz Beloit One Network |
$113.13
|
| Rate for Payer: Quartz Commercial |
$138.53
|
| Rate for Payer: WEA Trust Commercial |
$126.98
|
| Rate for Payer: WPS Commercial |
$171.01
|
|
|
HOLDER TUBE ENDOTRACHEAL NEONATE GRIP 42-2540
|
Facility
|
OP
|
$222.00
|
|
| Hospital Charge Code |
2973019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.65 |
| Max. Negotiated Rate |
$212.41 |
| Rate for Payer: Aetna Commercial |
$207.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.56
|
| Rate for Payer: Aetna Managed Medicare |
$64.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$110.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.37
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$212.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.20
|
| Rate for Payer: Health EOS Commercial |
$205.48
|
| Rate for Payer: HFN Commercial |
$212.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.16
|
| Rate for Payer: Multiplan Commercial |
$184.70
|
| Rate for Payer: NAPHCARE Commercial |
$138.53
|
| Rate for Payer: Preferred Network Access Commercial |
$212.41
|
| Rate for Payer: Quartz Beloit One Network |
$113.13
|
| Rate for Payer: Quartz Commercial |
$150.07
|
| Rate for Payer: Quartz Medicare Advantage |
$138.53
|
| Rate for Payer: The Alliance Commercial |
$115.44
|
| Rate for Payer: WEA Trust Commercial |
$126.98
|
| Rate for Payer: WPS Commercial |
$171.01
|
|
|
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 |
$628.12 |
| Max. Negotiated Rate |
$2,063.82 |
| Rate for Payer: Aetna Commercial |
$2,018.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,929.22
|
| Rate for Payer: Aetna Managed Medicare |
$628.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,458.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,121.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,076.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,188.94
|
| Rate for Payer: Cash Price |
$647.10
|
| Rate for Payer: Cigna Commercial |
$2,063.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,255.37
|
| Rate for Payer: Health EOS Commercial |
$1,996.52
|
| Rate for Payer: HFN Commercial |
$2,063.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,682.46
|
| Rate for Payer: Multiplan Commercial |
$1,794.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,345.97
|
| Rate for Payer: Preferred Network Access Commercial |
$2,063.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,099.21
|
| Rate for Payer: Quartz Commercial |
$1,458.13
|
| Rate for Payer: Quartz Medicare Advantage |
$1,345.97
|
| Rate for Payer: The Alliance Commercial |
$1,121.64
|
| Rate for Payer: WEA Trust Commercial |
$1,233.80
|
| Rate for Payer: WPS Commercial |
$1,661.54
|
|
|
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 |
$1,099.21 |
| Max. Negotiated Rate |
$2,063.82 |
| Rate for Payer: Aetna Commercial |
$2,018.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,929.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,188.94
|
| Rate for Payer: Cash Price |
$647.10
|
| Rate for Payer: Cigna Commercial |
$2,063.82
|
| Rate for Payer: Health EOS Commercial |
$1,996.52
|
| Rate for Payer: HFN Commercial |
$2,063.82
|
| Rate for Payer: Multiplan Commercial |
$1,794.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,063.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,099.21
|
| Rate for Payer: Quartz Commercial |
$1,345.97
|
| Rate for Payer: WEA Trust Commercial |
$1,233.80
|
| Rate for Payer: WPS Commercial |
$1,661.54
|
|
|
Holter Monitor 24 hr
|
Professional
|
Both
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$17.74 |
| Max. Negotiated Rate |
$823.99 |
| Rate for Payer: Aetna Commercial |
$823.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$745.93
|
| Rate for Payer: Aetna Managed Medicare |
$17.74
|
| Rate for Payer: Anthem Medicare Advantage |
$17.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.74
|
| 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 |
$823.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.74
|
| Rate for Payer: Health EOS Commercial |
$789.30
|
| Rate for Payer: HFN Commercial |
$823.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.74
|
| Rate for Payer: Multiplan Commercial |
$693.89
|
| Rate for Payer: NAPHCARE Commercial |
$26.61
|
| Rate for Payer: Preferred Network Access Commercial |
$823.99
|
| Rate for Payer: Quartz Beloit One Network |
$381.64
|
| Rate for Payer: Quartz Commercial |
$494.40
|
| Rate for Payer: Quartz Medicare Advantage |
$17.74
|
| Rate for Payer: The Alliance Commercial |
$67.42
|
| Rate for Payer: United Healthcare Medicaid |
$47.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.74
|
| Rate for Payer: WEA Trust Commercial |
$477.05
|
| Rate for Payer: WPS Commercial |
$70.97
|
|
|
Holter Monitor 24 hr
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$140.02 |
| Max. Negotiated Rate |
$797.97 |
| Rate for Payer: Aetna Commercial |
$780.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$745.93
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$563.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$433.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$416.33
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$459.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$797.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$485.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$771.95
|
| Rate for Payer: HFN Commercial |
$797.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$693.89
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$797.97
|
| Rate for Payer: Quartz Beloit One Network |
$425.01
|
| Rate for Payer: Quartz Commercial |
$563.78
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$650.52
|
| Rate for Payer: WEA Trust Commercial |
$477.05
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$642.43
|
|
|
Holter Monitor 24 hr
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382944
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$425.01 |
| Max. Negotiated Rate |
$797.97 |
| Rate for Payer: Aetna Commercial |
$780.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$745.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$459.70
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Cigna Commercial |
$797.97
|
| Rate for Payer: Health EOS Commercial |
$771.95
|
| Rate for Payer: HFN Commercial |
$797.97
|
| Rate for Payer: Multiplan Commercial |
$693.89
|
| Rate for Payer: Preferred Network Access Commercial |
$797.97
|
| Rate for Payer: Quartz Beloit One Network |
$425.01
|
| Rate for Payer: Quartz Commercial |
$520.42
|
| Rate for Payer: WEA Trust Commercial |
$477.05
|
| Rate for Payer: WPS Commercial |
$642.43
|
|
|
Holter Monitor 48 hr
|
Facility
|
IP
|
$1,666.00
|
|
|
Service Code
|
CPT 93225
|
| Hospital Charge Code |
5382945
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$848.99 |
| Max. Negotiated Rate |
$1,594.03 |
| Rate for Payer: Aetna Commercial |
$1,559.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,490.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$918.30
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,594.03
|
| Rate for Payer: Health EOS Commercial |
$1,542.05
|
| Rate for Payer: HFN Commercial |
$1,594.03
|
| Rate for Payer: Multiplan Commercial |
$1,386.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,594.03
|
| Rate for Payer: Quartz Beloit One Network |
$848.99
|
| Rate for Payer: Quartz Commercial |
$1,039.58
|
| Rate for Payer: WEA Trust Commercial |
$952.95
|
| Rate for Payer: WPS Commercial |
$1,283.32
|
|
