|
SHUNT AHMED FP7-10-0029
|
Facility
IP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6174991
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,409.82 |
| Max. Negotiated Rate |
$4,524.56 |
| Rate for Payer: Aetna Commercial |
$4,426.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,606.54
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,524.56
|
| Rate for Payer: Health EOS Commercial |
$4,377.02
|
| Rate for Payer: HFN Commercial |
$4,524.56
|
| Rate for Payer: Multiplan Commercial |
$3,934.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,950.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,524.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,409.82
|
| Rate for Payer: Quartz Commercial |
$2,950.80
|
| Rate for Payer: WEA Trust Commercial |
$2,704.90
|
| Rate for Payer: WPS Commercial |
$3,642.76
|
|
|
SHUNT AHMED FP7-10-0029
|
Facility
OP
|
$4,918.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6174991
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,377.04 |
| Max. Negotiated Rate |
$4,524.56 |
| Rate for Payer: Aetna Commercial |
$4,426.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,229.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,196.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,459.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,360.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,606.54
|
| Rate for Payer: Cash Price |
$1,475.40
|
| Rate for Payer: Cigna Commercial |
$4,524.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,752.11
|
| Rate for Payer: Health EOS Commercial |
$4,377.02
|
| Rate for Payer: HFN Commercial |
$4,524.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,688.50
|
| Rate for Payer: Multiplan Commercial |
$3,934.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,950.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,524.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,409.82
|
| Rate for Payer: Quartz Commercial |
$3,196.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,950.80
|
| Rate for Payer: WEA Trust Commercial |
$2,704.90
|
| Rate for Payer: WPS Commercial |
$3,642.76
|
|
|
SHUNT CLEARVIEW INTRACORONARY 1.5MM 31150
|
Facility
IP
|
$1,374.00
|
|
| Hospital Charge Code |
4017906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$673.26 |
| Max. Negotiated Rate |
$1,264.08 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$824.40
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT CLEARVIEW INTRACORONARY 1.5MM 31150
|
Facility
OP
|
$1,374.00
|
|
| Hospital Charge Code |
4017906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$5,496.00 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.64
|
| Rate for Payer: Aetna Managed Medicare |
$384.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$687.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.89
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.50
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$893.10
|
| Rate for Payer: Quartz Medicare Advantage |
$824.40
|
| Rate for Payer: The Alliance Commercial |
$5,496.00
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT CLEARVIEW INTRACORONARY 1MM 31100
|
Facility
IP
|
$1,374.00
|
|
| Hospital Charge Code |
4017905
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$673.26 |
| Max. Negotiated Rate |
$1,264.08 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$824.40
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT CLEARVIEW INTRACORONARY 1MM 31100
|
Facility
OP
|
$1,374.00
|
|
| Hospital Charge Code |
4017905
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$5,496.00 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.64
|
| Rate for Payer: Aetna Managed Medicare |
$384.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$687.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.89
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.50
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$893.10
|
| Rate for Payer: Quartz Medicare Advantage |
$824.40
|
| Rate for Payer: The Alliance Commercial |
$5,496.00
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT CLEARVIEW INTRACORONARY 2MM 31200
|
Facility
OP
|
$1,374.00
|
|
| Hospital Charge Code |
4017907
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$384.72 |
| Max. Negotiated Rate |
$5,496.00 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.64
|
| Rate for Payer: Aetna Managed Medicare |
$384.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$687.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.89
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.50
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$893.10
|
| Rate for Payer: Quartz Medicare Advantage |
$824.40
|
| Rate for Payer: The Alliance Commercial |
$5,496.00
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT CLEARVIEW INTRACORONARY 2MM 31200
|
Facility
IP
|
$1,374.00
|
|
| Hospital Charge Code |
4017907
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$673.26 |
| Max. Negotiated Rate |
$1,264.08 |
| Rate for Payer: Aetna Commercial |
$1,236.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.22
|
| Rate for Payer: Cash Price |
$412.20
|
| Rate for Payer: Cigna Commercial |
$1,264.08
|
| Rate for Payer: Health EOS Commercial |
$1,222.86
|
| Rate for Payer: HFN Commercial |
$1,264.08
|
| Rate for Payer: Multiplan Commercial |
$1,099.20
|
| Rate for Payer: NAPHCARE Commercial |
$824.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,264.08
|
| Rate for Payer: Quartz Beloit One Network |
$673.26
|
| Rate for Payer: Quartz Commercial |
$824.40
|
| Rate for Payer: WEA Trust Commercial |
$755.70
|
| Rate for Payer: WPS Commercial |
$1,017.72
|
|
|
SHUNT KIT ARGYLE CAROTID ARTERY 8888577775
|
Facility
IP
|
$701.00
|
|
| Hospital Charge Code |
5179006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$343.49 |
| Max. Negotiated Rate |
$644.92 |
| Rate for Payer: Aetna Commercial |
$630.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$371.53
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$644.92
|
| Rate for Payer: Health EOS Commercial |
$623.89
|
| Rate for Payer: HFN Commercial |
$644.92
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: NAPHCARE Commercial |
$420.60
|
| Rate for Payer: Preferred Network Access Commercial |
$644.92
|
| Rate for Payer: Quartz Beloit One Network |
$343.49
|
| Rate for Payer: Quartz Commercial |
$420.60
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
SHUNT KIT ARGYLE CAROTID ARTERY 8888577775
|
Facility
OP
|
$701.00
|
|
| Hospital Charge Code |
5179006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.28 |
| Max. Negotiated Rate |
$2,804.00 |
| Rate for Payer: Aetna Commercial |
$630.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.86
|
| Rate for Payer: Aetna Managed Medicare |
$196.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$455.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$350.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$336.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$371.53
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$644.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$392.28
|
| Rate for Payer: Health EOS Commercial |
$623.89
|
| Rate for Payer: HFN Commercial |
$644.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.75
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: NAPHCARE Commercial |
$420.60
|
| Rate for Payer: Preferred Network Access Commercial |
$644.92
|
| Rate for Payer: Quartz Beloit One Network |
$343.49
|
| Rate for Payer: Quartz Commercial |
$455.65
|
| Rate for Payer: Quartz Medicare Advantage |
$420.60
|
| Rate for Payer: The Alliance Commercial |
$2,804.00
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
SHUNT PRUITT-INAHARA CAROTID e2012-10
|
Facility
OP
|
$3,406.00
|
|
| Hospital Charge Code |
2965262
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$953.68 |
| Max. Negotiated Rate |
$13,624.00 |
| Rate for Payer: Aetna Commercial |
$3,065.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,929.16
|
| Rate for Payer: Aetna Managed Medicare |
$953.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,213.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,703.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,634.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,805.18
|
| Rate for Payer: Cash Price |
$1,021.80
|
| Rate for Payer: Cigna Commercial |
$3,133.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,906.00
|
| Rate for Payer: Health EOS Commercial |
$3,031.34
|
| Rate for Payer: HFN Commercial |
$3,133.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,554.50
|
| Rate for Payer: Multiplan Commercial |
$2,724.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,043.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,133.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,668.94
|
| Rate for Payer: Quartz Commercial |
$2,213.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,043.60
|
| Rate for Payer: The Alliance Commercial |
$13,624.00
|
| Rate for Payer: WEA Trust Commercial |
$1,873.30
|
| Rate for Payer: WPS Commercial |
$2,522.82
|
|
|
SHUNT PRUITT-INAHARA CAROTID e2012-10
|
Facility
IP
|
$3,406.00
|
|
| Hospital Charge Code |
2965262
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,668.94 |
| Max. Negotiated Rate |
$3,133.52 |
| Rate for Payer: Aetna Commercial |
$3,065.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,805.18
|
| Rate for Payer: Cash Price |
$1,021.80
|
| Rate for Payer: Cigna Commercial |
$3,133.52
|
| Rate for Payer: Health EOS Commercial |
$3,031.34
|
| Rate for Payer: HFN Commercial |
$3,133.52
|
| Rate for Payer: Multiplan Commercial |
$2,724.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,043.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,133.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,668.94
|
| Rate for Payer: Quartz Commercial |
$2,043.60
|
| Rate for Payer: WEA Trust Commercial |
$1,873.30
|
| Rate for Payer: WPS Commercial |
$2,522.82
|
|
|
Sickle Cell
|
Facility
OP
|
$92.00
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
979865
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$5.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.15
|
| Rate for Payer: Anthem Medicaid |
$5.69
|
| Rate for Payer: Anthem Medicare Advantage |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.51
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.69
|
| Rate for Payer: Dean Health Medicaid |
$5.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.51
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.51
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.51
|
| Rate for Payer: Managed Health Services Medicaid |
$5.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$8.26
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.69
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5.51
|
| Rate for Payer: The Alliance Commercial |
$368.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.51
|
| Rate for Payer: United Healthcare PPO |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: Wellcare Medicare |
$5.51
|
| Rate for Payer: WMAP Medicaid |
$5.69
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Sickle Cell
|
Facility
IP
|
$92.00
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
979865
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Sickle Cell
|
Professional
|
$92.00
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
979865
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$87.40 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$5.51
|
| Rate for Payer: Anthem Medicare Advantage |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.51
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$87.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.51
|
| Rate for Payer: Health EOS Commercial |
$83.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: Preferred Network Access Commercial |
$87.40
|
| Rate for Payer: Quartz Beloit One Network |
$40.48
|
| Rate for Payer: Quartz Commercial |
$52.44
|
| Rate for Payer: Quartz Medicare Advantage |
$5.51
|
| Rate for Payer: The Alliance Commercial |
$21.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.51
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$24.24
|
|
|
.Sickle Cell Screen
|
Facility
OP
|
$18.68
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
6238138
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$74.72 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.15
|
| Rate for Payer: Anthem Medicaid |
$5.69
|
| Rate for Payer: Anthem Medicare Advantage |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.51
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cigna Commercial |
$17.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.69
|
| Rate for Payer: Dean Health Medicaid |
$5.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.51
|
| Rate for Payer: Health EOS Commercial |
$16.63
|
| Rate for Payer: HFN Commercial |
$17.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.51
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.51
|
| Rate for Payer: Managed Health Services Medicaid |
$5.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$14.94
|
| Rate for Payer: NAPHCARE Commercial |
$8.26
|
| Rate for Payer: Preferred Network Access Commercial |
$17.19
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.69
|
| Rate for Payer: Quartz Beloit One Network |
$9.15
|
| Rate for Payer: Quartz Commercial |
$12.14
|
| Rate for Payer: Quartz Medicare Advantage |
$5.51
|
| Rate for Payer: The Alliance Commercial |
$74.72
|
| Rate for Payer: United Healthcare Medicaid |
$5.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.51
|
| Rate for Payer: United Healthcare PPO |
$14.01
|
| Rate for Payer: WEA Trust Commercial |
$10.27
|
| Rate for Payer: Wellcare Medicare |
$5.51
|
| Rate for Payer: WMAP Medicaid |
$5.69
|
| Rate for Payer: WPS Commercial |
$13.84
|
|
|
.Sickle Cell Screen
|
Professional
|
$18.68
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
6238138
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$24.24 |
| Rate for Payer: Aetna Commercial |
$17.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.51
|
| Rate for Payer: Anthem Medicare Advantage |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.51
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cigna Commercial |
$17.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.51
|
| Rate for Payer: Health EOS Commercial |
$17.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$14.94
|
| Rate for Payer: Preferred Network Access Commercial |
$17.75
|
| Rate for Payer: Quartz Beloit One Network |
$8.22
|
| Rate for Payer: Quartz Commercial |
$10.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5.51
|
| Rate for Payer: The Alliance Commercial |
$21.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.51
|
| Rate for Payer: WEA Trust Commercial |
$10.27
|
| Rate for Payer: WPS Commercial |
$24.24
|
|
|
.Sickle Cell Screen
|
Facility
IP
|
$18.68
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
6238138
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$17.19 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.90
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cigna Commercial |
$17.19
|
| Rate for Payer: Health EOS Commercial |
$16.63
|
| Rate for Payer: HFN Commercial |
$17.19
|
| Rate for Payer: Multiplan Commercial |
$14.94
|
| Rate for Payer: NAPHCARE Commercial |
$11.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17.19
|
| Rate for Payer: Quartz Beloit One Network |
$9.15
|
| Rate for Payer: Quartz Commercial |
$11.21
|
| Rate for Payer: WEA Trust Commercial |
$10.27
|
| Rate for Payer: WPS Commercial |
$13.84
|
|
|
S & I Code 74425
|
Facility
IP
|
$1,032.00
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
4125411
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$505.68 |
| Max. Negotiated Rate |
$949.44 |
| Rate for Payer: Aetna Commercial |
$928.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.96
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$949.44
|
| Rate for Payer: Health EOS Commercial |
$918.48
|
| Rate for Payer: HFN Commercial |
$949.44
|
| Rate for Payer: Multiplan Commercial |
$825.60
|
| Rate for Payer: NAPHCARE Commercial |
$619.20
|
| Rate for Payer: Preferred Network Access Commercial |
$949.44
|
| Rate for Payer: Quartz Beloit One Network |
$505.68
|
| Rate for Payer: Quartz Commercial |
$619.20
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
S & I Code 74425
|
Facility
OP
|
$1,032.00
|
|
|
Service Code
|
CPT 74425
|
| Hospital Charge Code |
4125411
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$1,414.05 |
| Rate for Payer: Aetna Commercial |
$928.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.52
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$516.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$495.36
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$949.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$918.48
|
| Rate for Payer: HFN Commercial |
$949.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$825.60
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$949.44
|
| Rate for Payer: Quartz Beloit One Network |
$505.68
|
| Rate for Payer: Quartz Commercial |
$670.80
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$439.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
SIDEKICK NEEDLE COAPTITE 21GA X 14.6 IN M0068903040
|
Facility
IP
|
$951.00
|
|
| Hospital Charge Code |
5382983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$465.99 |
| Max. Negotiated Rate |
$874.92 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$570.60
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
SIDEKICK NEEDLE COAPTITE 21GA X 14.6 IN M0068903040
|
Facility
OP
|
$951.00
|
|
| Hospital Charge Code |
5382983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.28 |
| Max. Negotiated Rate |
$3,804.00 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Aetna Managed Medicare |
$266.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.18
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.25
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$618.15
|
| Rate for Payer: Quartz Medicare Advantage |
$570.60
|
| Rate for Payer: The Alliance Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
SIDEPLATE 4HL 135 DHS LCP DHHS
|
Facility
IP
|
$5,722.00
|
|
| Hospital Charge Code |
2966582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,803.78 |
| Max. Negotiated Rate |
$5,264.24 |
| Rate for Payer: Aetna Commercial |
$5,149.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,032.66
|
| Rate for Payer: Cash Price |
$1,716.60
|
| Rate for Payer: Cigna Commercial |
$5,264.24
|
| Rate for Payer: Health EOS Commercial |
$5,092.58
|
| Rate for Payer: HFN Commercial |
$5,264.24
|
| Rate for Payer: Multiplan Commercial |
$4,577.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,433.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,264.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,803.78
|
| Rate for Payer: Quartz Commercial |
$3,433.20
|
| Rate for Payer: WEA Trust Commercial |
$3,147.10
|
| Rate for Payer: WPS Commercial |
$4,238.29
|
|
|
SIDEPLATE 4HL 135 DHS LCP DHHS
|
Facility
OP
|
$5,722.00
|
|
| Hospital Charge Code |
2966582
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,602.16 |
| Max. Negotiated Rate |
$22,888.00 |
| Rate for Payer: Quartz Medicare Advantage |
$3,433.20
|
| Rate for Payer: Aetna Commercial |
$5,149.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,920.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,602.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,719.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,861.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,746.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,032.66
|
| Rate for Payer: Cash Price |
$1,716.60
|
| Rate for Payer: Cigna Commercial |
$5,264.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,202.03
|
| Rate for Payer: Health EOS Commercial |
$5,092.58
|
| Rate for Payer: HFN Commercial |
$5,264.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,291.50
|
| Rate for Payer: Multiplan Commercial |
$4,577.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,433.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,264.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,803.78
|
| Rate for Payer: Quartz Commercial |
$3,719.30
|
| Rate for Payer: The Alliance Commercial |
$22,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,147.10
|
| Rate for Payer: WPS Commercial |
$4,238.29
|
|
|
SIDEPLATE DHHS SYNTHES
|
Facility
OP
|
$5,722.00
|
|
| Hospital Charge Code |
2966583
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,602.16 |
| Max. Negotiated Rate |
$22,888.00 |
| Rate for Payer: Aetna Commercial |
$5,149.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,920.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,602.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,719.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,861.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,746.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,032.66
|
| Rate for Payer: Cash Price |
$1,716.60
|
| Rate for Payer: Cigna Commercial |
$5,264.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,202.03
|
| Rate for Payer: Health EOS Commercial |
$5,092.58
|
| Rate for Payer: HFN Commercial |
$5,264.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,291.50
|
| Rate for Payer: Multiplan Commercial |
$4,577.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,433.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,264.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,803.78
|
| Rate for Payer: Quartz Commercial |
$3,719.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,433.20
|
| Rate for Payer: The Alliance Commercial |
$22,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,147.10
|
| Rate for Payer: WPS Commercial |
$4,238.29
|
|
