|
ART SURFACE PSN VE CR 3-9 CD 18MM RT 42-5220-004-18
|
Facility
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641024
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 11MM LT 42-5120-006-11
|
Facility
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.88 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,543.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,455.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,701.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,385.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,210.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,908.25
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,578.25
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,701.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
|
ART SURFACE PSN VE CR 7-12 GH 11MM LT 42-5120-006-11
|
Facility
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,297.79 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
|
ART SURFACE PSN VE CR 7-12 GH 13MM LT 42-5120-006-13
|
Facility
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 13MM LT 42-5120-006-13
|
Facility
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 14MM LT 42-5120-006-14
|
Facility
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 14MM LT 42-5120-006-14
|
Facility
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 16MM LT 42-5120-006-16
|
Facility
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 16MM LT 42-5120-006-16
|
Facility
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 18MM LT 42-5120-006-18
|
Facility
OP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE CR 7-12 GH 18MM LT 42-5120-006-18
|
Facility
IP
|
$8,446.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4641016
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
ART SURFACE PSN VE MC 6-7 EF 11MM RT 42-5221-007-11
|
Facility
OP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246160
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,739.75 |
| Max. Negotiated Rate |
$5,716.32 |
| Rate for Payer: Aetna Commercial |
$5,592.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,343.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,739.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,038.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,106.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,982.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,293.10
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,716.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,477.01
|
| Rate for Payer: Health EOS Commercial |
$5,529.92
|
| Rate for Payer: HFN Commercial |
$5,716.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,660.04
|
| Rate for Payer: Multiplan Commercial |
$4,970.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,728.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,716.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,044.56
|
| Rate for Payer: Quartz Commercial |
$4,038.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,728.03
|
| Rate for Payer: WEA Trust Commercial |
$3,417.36
|
| Rate for Payer: WPS Commercial |
$4,602.26
|
|
|
ART SURFACE PSN VE MC 6-7 EF 11MM RT 42-5221-007-11
|
Facility
IP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246160
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,044.56 |
| Max. Negotiated Rate |
$5,716.32 |
| Rate for Payer: Aetna Commercial |
$5,592.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,293.10
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,716.32
|
| Rate for Payer: Health EOS Commercial |
$5,529.92
|
| Rate for Payer: HFN Commercial |
$5,716.32
|
| Rate for Payer: Multiplan Commercial |
$4,970.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,728.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,716.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,044.56
|
| Rate for Payer: Quartz Commercial |
$3,728.03
|
| Rate for Payer: WEA Trust Commercial |
$3,417.36
|
| Rate for Payer: WPS Commercial |
$4,602.26
|
|
|
ART SURFACE PSN VE MC 8-11 GH 11MM LT 42-5121-009-11
|
Facility
OP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,739.75 |
| Max. Negotiated Rate |
$5,716.32 |
| Rate for Payer: Aetna Commercial |
$5,592.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,343.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,739.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,038.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,106.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,982.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,293.10
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,716.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,477.01
|
| Rate for Payer: Health EOS Commercial |
$5,529.92
|
| Rate for Payer: HFN Commercial |
$5,716.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,660.04
|
| Rate for Payer: Multiplan Commercial |
$4,970.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,728.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,716.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,044.56
|
| Rate for Payer: Quartz Commercial |
$4,038.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,728.03
|
| Rate for Payer: WEA Trust Commercial |
$3,417.36
|
| Rate for Payer: WPS Commercial |
$4,602.26
|
|
|
ART SURFACE PSN VE MC 8-11 GH 11MM LT 42-5121-009-11
|
Facility
IP
|
$6,213.39
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,044.56 |
| Max. Negotiated Rate |
$5,716.32 |
| Rate for Payer: Aetna Commercial |
$5,592.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,293.10
|
| Rate for Payer: Cash Price |
$1,864.02
|
| Rate for Payer: Cigna Commercial |
$5,716.32
|
| Rate for Payer: Health EOS Commercial |
$5,529.92
|
| Rate for Payer: HFN Commercial |
$5,716.32
|
| Rate for Payer: Multiplan Commercial |
$4,970.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,728.03
|
| Rate for Payer: Preferred Network Access Commercial |
$5,716.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,044.56
|
| Rate for Payer: Quartz Commercial |
$3,728.03
|
| Rate for Payer: WEA Trust Commercial |
$3,417.36
|
| Rate for Payer: WPS Commercial |
$4,602.26
|
|
|
ASCA IgA
|
Professional
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$75.99 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$65.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$68.40
|
| Rate for Payer: Quartz Beloit One Network |
$31.68
|
| Rate for Payer: Quartz Commercial |
$41.04
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$68.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$75.99
|
|
|
ASCA IgA
|
Facility
OP
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
ASCA IgA
|
Facility
IP
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
ASCA IgG
|
Facility
IP
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$43.20
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
ASCA IgG
|
Facility
OP
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$66.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$64.08
|
| Rate for Payer: HFN Commercial |
$66.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$66.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$35.28
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$288.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$53.33
|
|
|
ASCA IgG
|
Professional
|
$72.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
2770815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$75.99 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$65.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$68.40
|
| Rate for Payer: Quartz Beloit One Network |
$31.68
|
| Rate for Payer: Quartz Commercial |
$41.04
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$68.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: WEA Trust Commercial |
$39.60
|
| Rate for Payer: WPS Commercial |
$75.99
|
|
|
ASCA IgG Ab
|
Professional
|
$84.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439032
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$79.80 |
| Rate for Payer: Aetna Commercial |
$79.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$12.25
|
| Rate for Payer: Anthem Medicare Advantage |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.25
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$79.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.25
|
| Rate for Payer: Health EOS Commercial |
$76.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$79.80
|
| Rate for Payer: Quartz Beloit One Network |
$36.96
|
| Rate for Payer: Quartz Commercial |
$47.88
|
| Rate for Payer: Quartz Medicare Advantage |
$12.25
|
| Rate for Payer: The Alliance Commercial |
$48.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.25
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$53.90
|
|
|
ASCA IgG Ab
|
Facility
OP
|
$84.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439032
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$12.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.34
|
| Rate for Payer: Anthem Medicaid |
$7.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.25
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.15
|
| Rate for Payer: Dean Health Medicaid |
$7.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.25
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.25
|
| Rate for Payer: Managed Health Services Medicaid |
$7.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.38
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.15
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12.25
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.25
|
| Rate for Payer: United Healthcare PPO |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: Wellcare Medicare |
$12.25
|
| Rate for Payer: WMAP Medicaid |
$7.15
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
ASCA IgG Ab
|
Facility
IP
|
$84.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439032
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Aspartate Aminotransferase
|
Professional
|
$85.00
|
|
|
Service Code
|
CPT 84450
|
| Hospital Charge Code |
633633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$80.75 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.18
|
| Rate for Payer: Anthem Medicare Advantage |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.18
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.18
|
| Rate for Payer: Health EOS Commercial |
$77.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: Preferred Network Access Commercial |
$80.75
|
| Rate for Payer: Quartz Beloit One Network |
$37.40
|
| Rate for Payer: Quartz Commercial |
$48.45
|
| Rate for Payer: Quartz Medicare Advantage |
$5.18
|
| Rate for Payer: The Alliance Commercial |
$20.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$22.79
|
|
