|
PULMONARY EMBOLISM WITHOUT MCC
|
Facility
|
IP
|
$22,004.00
|
|
|
Service Code
|
MSDRG 176
|
| Min. Negotiated Rate |
$7,915.09 |
| Max. Negotiated Rate |
$22,004.00 |
| Rate for Payer: Wellcare Medicare |
$7,915.09
|
| Rate for Payer: Aetna Managed Medicare |
$7,915.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,203.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,186.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,527.96
|
| Rate for Payer: Anthem Medicare Advantage |
$7,915.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,915.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,915.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,915.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,907.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,915.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,904.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,915.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,915.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,915.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,915.09
|
| Rate for Payer: NAPHCARE Commercial |
$11,872.64
|
| Rate for Payer: Quartz Medicare Advantage |
$7,915.09
|
| Rate for Payer: The Alliance Commercial |
$22,004.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,915.09
|
| Rate for Payer: United Healthcare PPO |
$12,381.62
|
|
|
Pulmonary Stress Test - 6 min walk - Pulmonary Function Test Charge
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
5381709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$95.04 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$128.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.04
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| 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 |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| 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 |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$128.70
|
| 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 |
$148.50
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
Pulmonary Stress Test - 6 min walk - Pulmonary Function Test Charge
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
5381709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$97.02 |
| Max. Negotiated Rate |
$182.16 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.94
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna Commercial |
$182.16
|
| Rate for Payer: Health EOS Commercial |
$176.22
|
| Rate for Payer: HFN Commercial |
$182.16
|
| Rate for Payer: Multiplan Commercial |
$158.40
|
| Rate for Payer: NAPHCARE Commercial |
$118.80
|
| Rate for Payer: Preferred Network Access Commercial |
$182.16
|
| Rate for Payer: Quartz Beloit One Network |
$97.02
|
| Rate for Payer: Quartz Commercial |
$118.80
|
| Rate for Payer: WEA Trust Commercial |
$108.90
|
| Rate for Payer: WPS Commercial |
$146.66
|
|
|
Pulmonary Stress Testing 94618
|
Professional
|
Both
|
$466.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
1152824
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.57 |
| Max. Negotiated Rate |
$442.70 |
| Rate for Payer: Aetna Commercial |
$442.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.76
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$442.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.60
|
| Rate for Payer: Health EOS Commercial |
$424.06
|
| Rate for Payer: HFN Commercial |
$442.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.60
|
| Rate for Payer: Multiplan Commercial |
$372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$442.70
|
| Rate for Payer: Quartz Beloit One Network |
$205.04
|
| Rate for Payer: Quartz Commercial |
$265.62
|
| Rate for Payer: The Alliance Commercial |
$233.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.57
|
| Rate for Payer: WEA Trust Commercial |
$256.30
|
| Rate for Payer: WPS Commercial |
$345.17
|
|
|
Pulmonary Stress Test - Resp
|
Facility
|
IP
|
$1,137.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
4830606
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$557.13 |
| Max. Negotiated Rate |
$1,046.04 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$977.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| Rate for Payer: Multiplan Commercial |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$682.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$682.20
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
Pulmonary Stress Test - Resp
|
Facility
|
OP
|
$1,137.00
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
4830606
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$1,046.04 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$977.82
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$545.76
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| 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 |
$341.10
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| 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 |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$739.05
|
| 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 |
$852.75
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
Pulmonary Stress Test/Simple 9461826
|
Professional
|
Both
|
$466.00
|
|
|
Service Code
|
CPT 94618 26
|
| Hospital Charge Code |
5366631
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.57 |
| Max. Negotiated Rate |
$442.70 |
| Rate for Payer: Aetna Commercial |
$442.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.76
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$442.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.60
|
| Rate for Payer: Health EOS Commercial |
$424.06
|
| Rate for Payer: HFN Commercial |
$442.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$77.27
|
| Rate for Payer: Multiplan Commercial |
$372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$442.70
|
| Rate for Payer: Quartz Beloit One Network |
$205.04
|
| Rate for Payer: Quartz Commercial |
$265.62
|
| Rate for Payer: The Alliance Commercial |
$233.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.57
|
| Rate for Payer: WEA Trust Commercial |
$256.30
|
| Rate for Payer: WPS Commercial |
$345.17
|
|
|
Pulse Oximetry Monitor - Daily Charges
|
Facility
|
OP
|
$958.00
|
|
| Hospital Charge Code |
3003956
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$268.24 |
| Max. Negotiated Rate |
$3,832.00 |
| Rate for Payer: Aetna Commercial |
$862.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$823.88
|
| Rate for Payer: Aetna Managed Medicare |
$268.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$622.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$459.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$507.74
|
| Rate for Payer: Cash Price |
$287.40
|
| Rate for Payer: Cigna Commercial |
$881.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.10
|
| Rate for Payer: Health EOS Commercial |
$852.62
|
| Rate for Payer: HFN Commercial |
$881.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$718.50
|
| Rate for Payer: Multiplan Commercial |
$766.40
|
| Rate for Payer: NAPHCARE Commercial |
$574.80
|
| Rate for Payer: Preferred Network Access Commercial |
$881.36
|
| Rate for Payer: Quartz Beloit One Network |
$469.42
|
| Rate for Payer: Quartz Commercial |
$622.70
|
| Rate for Payer: Quartz Medicare Advantage |
$574.80
|
| Rate for Payer: The Alliance Commercial |
$3,832.00
|
| Rate for Payer: WEA Trust Commercial |
$526.90
|
| Rate for Payer: WPS Commercial |
$709.59
|
|
|
Pulse Oximetry Monitor - Daily Charges
|
Facility
|
IP
|
$958.00
|
|
| Hospital Charge Code |
3003956
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$469.42 |
| Max. Negotiated Rate |
$881.36 |
| Rate for Payer: Aetna Commercial |
$862.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$823.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$507.74
|
| Rate for Payer: Cash Price |
$287.40
|
| Rate for Payer: Cigna Commercial |
$881.36
|
| Rate for Payer: Health EOS Commercial |
$852.62
|
| Rate for Payer: HFN Commercial |
$881.36
|
| Rate for Payer: Multiplan Commercial |
$766.40
|
| Rate for Payer: NAPHCARE Commercial |
$574.80
|
| Rate for Payer: Preferred Network Access Commercial |
$881.36
|
| Rate for Payer: Quartz Beloit One Network |
$469.42
|
| Rate for Payer: Quartz Commercial |
$574.80
|
| Rate for Payer: WEA Trust Commercial |
$526.90
|
| Rate for Payer: WPS Commercial |
$709.59
|
|
|
Pulse Oximetry Monitor - Nursery Daily Charges
|
Facility
|
IP
|
$411.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3003948
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$201.39 |
| Max. Negotiated Rate |
$378.12 |
| Rate for Payer: Aetna Commercial |
$369.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$353.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.83
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$378.12
|
| Rate for Payer: Health EOS Commercial |
$365.79
|
| Rate for Payer: HFN Commercial |
$378.12
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: NAPHCARE Commercial |
$246.60
|
| Rate for Payer: Preferred Network Access Commercial |
$378.12
|
| Rate for Payer: Quartz Beloit One Network |
$201.39
|
| Rate for Payer: Quartz Commercial |
$246.60
|
| Rate for Payer: WEA Trust Commercial |
$226.05
|
| Rate for Payer: WPS Commercial |
$304.43
|
|
|
Pulse Oximetry Monitor - Nursery Daily Charges
|
Facility
|
OP
|
$411.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
3003948
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$1,644.00 |
| Rate for Payer: Aetna Commercial |
$369.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$353.46
|
| Rate for Payer: Aetna Managed Medicare |
$115.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$267.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$205.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$197.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.83
|
| Rate for Payer: Cash Price |
$123.30
|
| Rate for Payer: Cigna Commercial |
$378.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.00
|
| Rate for Payer: Health EOS Commercial |
$365.79
|
| Rate for Payer: HFN Commercial |
$378.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$308.25
|
| Rate for Payer: Multiplan Commercial |
$328.80
|
| Rate for Payer: NAPHCARE Commercial |
$246.60
|
| Rate for Payer: Preferred Network Access Commercial |
$378.12
|
| Rate for Payer: Quartz Beloit One Network |
$201.39
|
| Rate for Payer: Quartz Commercial |
$267.15
|
| Rate for Payer: Quartz Medicare Advantage |
$246.60
|
| Rate for Payer: The Alliance Commercial |
$1,644.00
|
| Rate for Payer: United Healthcare PPO |
$308.25
|
| Rate for Payer: WEA Trust Commercial |
$226.05
|
| Rate for Payer: WPS Commercial |
$304.43
|
|
|
PUMP BOTTLE BIOFREEZE 32oz 081697408
|
Facility
|
OP
|
$598.00
|
|
| Hospital Charge Code |
2969785
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$167.44 |
| Max. Negotiated Rate |
$2,392.00 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$514.28
|
| Rate for Payer: Aetna Managed Medicare |
$167.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$388.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$287.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.94
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$550.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.64
|
| Rate for Payer: Health EOS Commercial |
$532.22
|
| Rate for Payer: HFN Commercial |
$550.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.50
|
| Rate for Payer: Multiplan Commercial |
$478.40
|
| Rate for Payer: NAPHCARE Commercial |
$358.80
|
| Rate for Payer: Preferred Network Access Commercial |
$550.16
|
| Rate for Payer: Quartz Beloit One Network |
$293.02
|
| Rate for Payer: Quartz Commercial |
$388.70
|
| Rate for Payer: Quartz Medicare Advantage |
$358.80
|
| Rate for Payer: The Alliance Commercial |
$2,392.00
|
| Rate for Payer: WEA Trust Commercial |
$328.90
|
| Rate for Payer: WPS Commercial |
$442.94
|
|
|
PUMP BOTTLE BIOFREEZE 32oz 081697408
|
Facility
|
IP
|
$598.00
|
|
| Hospital Charge Code |
2969785
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$293.02 |
| Max. Negotiated Rate |
$550.16 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$514.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.94
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$550.16
|
| Rate for Payer: Health EOS Commercial |
$532.22
|
| Rate for Payer: HFN Commercial |
$550.16
|
| Rate for Payer: Multiplan Commercial |
$478.40
|
| Rate for Payer: NAPHCARE Commercial |
$358.80
|
| Rate for Payer: Preferred Network Access Commercial |
$550.16
|
| Rate for Payer: Quartz Beloit One Network |
$293.02
|
| Rate for Payer: Quartz Commercial |
$358.80
|
| Rate for Payer: WEA Trust Commercial |
$328.90
|
| Rate for Payer: WPS Commercial |
$442.94
|
|
|
PUMP MENDA PURE TOUCH LIQUED
|
Facility
|
IP
|
$5,137.00
|
|
| Hospital Charge Code |
2971453
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,517.13 |
| Max. Negotiated Rate |
$4,726.04 |
| Rate for Payer: Aetna Commercial |
$4,623.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,417.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.61
|
| Rate for Payer: Cash Price |
$1,541.10
|
| Rate for Payer: Cigna Commercial |
$4,726.04
|
| Rate for Payer: Health EOS Commercial |
$4,571.93
|
| Rate for Payer: HFN Commercial |
$4,726.04
|
| Rate for Payer: Multiplan Commercial |
$4,109.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,082.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.13
|
| Rate for Payer: Quartz Commercial |
$3,082.20
|
| Rate for Payer: WEA Trust Commercial |
$2,825.35
|
| Rate for Payer: WPS Commercial |
$3,804.98
|
|
|
PUMP MENDA PURE TOUCH LIQUED
|
Facility
|
OP
|
$5,137.00
|
|
| Hospital Charge Code |
2971453
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,438.36 |
| Max. Negotiated Rate |
$20,548.00 |
| Rate for Payer: Aetna Commercial |
$4,623.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,417.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,438.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,339.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,568.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,465.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,722.61
|
| Rate for Payer: Cash Price |
$1,541.10
|
| Rate for Payer: Cigna Commercial |
$4,726.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,874.67
|
| Rate for Payer: Health EOS Commercial |
$4,571.93
|
| Rate for Payer: HFN Commercial |
$4,726.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,852.75
|
| Rate for Payer: Multiplan Commercial |
$4,109.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,082.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,726.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,517.13
|
| Rate for Payer: Quartz Commercial |
$3,339.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,082.20
|
| Rate for Payer: The Alliance Commercial |
$20,548.00
|
| Rate for Payer: WEA Trust Commercial |
$2,825.35
|
| Rate for Payer: WPS Commercial |
$3,804.98
|
|
|
PUMP SET POSITIVE W/PRE-PIERCD #W21137
|
Facility
|
OP
|
$272.00
|
|
| Hospital Charge Code |
2973133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.16 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$163.20
|
| Rate for Payer: The Alliance Commercial |
$1,088.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
PUMP SET POSITIVE W/PRE-PIERCD #W21137
|
Facility
|
IP
|
$272.00
|
|
| Hospital Charge Code |
2973133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
PUMP TUBE ID3.2
|
Facility
|
IP
|
$577.00
|
|
| Hospital Charge Code |
2973553
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$282.73 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
PUMP TUBE ID3.2
|
Facility
|
OP
|
$577.00
|
|
| Hospital Charge Code |
2973553
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.56 |
| Max. Negotiated Rate |
$2,308.00 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$161.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$375.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$288.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$322.89
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$432.75
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$375.05
|
| Rate for Payer: Quartz Medicare Advantage |
$346.20
|
| Rate for Payer: The Alliance Commercial |
$2,308.00
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
PUMP TUBE ID4.8
|
Facility
|
OP
|
$634.00
|
|
| Hospital Charge Code |
2983108
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$177.52 |
| Max. Negotiated Rate |
$2,536.00 |
| Rate for Payer: Aetna Commercial |
$570.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.24
|
| Rate for Payer: Aetna Managed Medicare |
$177.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$412.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$317.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$304.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.02
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$583.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.79
|
| Rate for Payer: Health EOS Commercial |
$564.26
|
| Rate for Payer: HFN Commercial |
$583.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$475.50
|
| Rate for Payer: Multiplan Commercial |
$507.20
|
| Rate for Payer: NAPHCARE Commercial |
$380.40
|
| Rate for Payer: Preferred Network Access Commercial |
$583.28
|
| Rate for Payer: Quartz Beloit One Network |
$310.66
|
| Rate for Payer: Quartz Commercial |
$412.10
|
| Rate for Payer: Quartz Medicare Advantage |
$380.40
|
| Rate for Payer: The Alliance Commercial |
$2,536.00
|
| Rate for Payer: WEA Trust Commercial |
$348.70
|
| Rate for Payer: WPS Commercial |
$469.60
|
|
|
PUMP TUBE ID4.8
|
Facility
|
IP
|
$634.00
|
|
| Hospital Charge Code |
2983108
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$310.66 |
| Max. Negotiated Rate |
$583.28 |
| Rate for Payer: Aetna Commercial |
$570.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.02
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$583.28
|
| Rate for Payer: Health EOS Commercial |
$564.26
|
| Rate for Payer: HFN Commercial |
$583.28
|
| Rate for Payer: Multiplan Commercial |
$507.20
|
| Rate for Payer: NAPHCARE Commercial |
$380.40
|
| Rate for Payer: Preferred Network Access Commercial |
$583.28
|
| Rate for Payer: Quartz Beloit One Network |
$310.66
|
| Rate for Payer: Quartz Commercial |
$380.40
|
| Rate for Payer: WEA Trust Commercial |
$348.70
|
| Rate for Payer: WPS Commercial |
$469.60
|
|
|
PUMP TUBING ARTHROSCOPY MAIN ARTHREX AR-6410
|
Facility
|
IP
|
$1,160.00
|
|
| Hospital Charge Code |
5074886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$568.40 |
| Max. Negotiated Rate |
$1,067.20 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$696.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
PUMP TUBING ARTHROSCOPY MAIN ARTHREX AR-6410
|
Facility
|
OP
|
$1,160.00
|
|
| Hospital Charge Code |
5074886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$4,640.00 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.60
|
| Rate for Payer: Aetna Managed Medicare |
$324.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$754.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$649.14
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$870.00
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$754.00
|
| Rate for Payer: Quartz Medicare Advantage |
$696.00
|
| Rate for Payer: The Alliance Commercial |
$4,640.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
Pump tubing changed - Peripheral IV Care:
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
3025930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$616.00 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Aetna Managed Medicare |
$43.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.18
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.50
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$100.10
|
| Rate for Payer: Quartz Medicare Advantage |
$92.40
|
| Rate for Payer: The Alliance Commercial |
$616.00
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
Pump tubing changed - Peripheral IV Care:
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
3025930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$75.46 |
| Max. Negotiated Rate |
$141.68 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$92.40
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
