|
Securement Device - Central IV Dressing:
|
Facility
|
OP
|
$152.00
|
|
| Hospital Charge Code |
3000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.56 |
| Max. Negotiated Rate |
$608.00 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$130.72
|
| Rate for Payer: Aetna Managed Medicare |
$42.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$139.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.06
|
| Rate for Payer: Health EOS Commercial |
$135.28
|
| Rate for Payer: HFN Commercial |
$139.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.00
|
| Rate for Payer: Multiplan Commercial |
$121.60
|
| Rate for Payer: NAPHCARE Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$139.84
|
| Rate for Payer: Quartz Beloit One Network |
$74.48
|
| Rate for Payer: Quartz Commercial |
$98.80
|
| Rate for Payer: Quartz Medicare Advantage |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$608.00
|
| Rate for Payer: WEA Trust Commercial |
$83.60
|
| Rate for Payer: WPS Commercial |
$112.59
|
|
|
Securement Device replaced - Central IV Dressing:
|
Facility
|
IP
|
$146.00
|
|
| Hospital Charge Code |
3004351
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Securement Device replaced - Central IV Dressing:
|
Facility
|
OP
|
$146.00
|
|
| Hospital Charge Code |
3004351
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: The Alliance Commercial |
$584.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Securement Device replaced - Urinary Catheter Secured
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
3031383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Securement Device replaced - Urinary Catheter Secured
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
3031383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Securement Device* - Urinary Catheter Secured:
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
5510850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Securement Device* - Urinary Catheter Secured:
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
5510850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Securement Device - Urinary Catheter Secured
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
3031384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Securement Device - Urinary Catheter Secured
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
3031384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
SECURESTRAP FIXATION DEVICE STRAP25
|
Facility
|
OP
|
$5,964.00
|
|
| Hospital Charge Code |
2969374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,669.92 |
| Max. Negotiated Rate |
$23,856.00 |
| Rate for Payer: Aetna Commercial |
$5,367.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.04
|
| Rate for Payer: Aetna Managed Medicare |
$1,669.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,876.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,982.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,862.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.92
|
| Rate for Payer: Cash Price |
$1,789.20
|
| Rate for Payer: Cigna Commercial |
$5,486.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,337.45
|
| Rate for Payer: Health EOS Commercial |
$5,307.96
|
| Rate for Payer: HFN Commercial |
$5,486.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,473.00
|
| Rate for Payer: Multiplan Commercial |
$4,771.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,578.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,486.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.36
|
| Rate for Payer: Quartz Commercial |
$3,876.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,578.40
|
| Rate for Payer: The Alliance Commercial |
$23,856.00
|
| Rate for Payer: WEA Trust Commercial |
$3,280.20
|
| Rate for Payer: WPS Commercial |
$4,417.53
|
|
|
SECURESTRAP FIXATION DEVICE STRAP25
|
Facility
|
IP
|
$5,964.00
|
|
| Hospital Charge Code |
2969374
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,922.36 |
| Max. Negotiated Rate |
$5,486.88 |
| Rate for Payer: Aetna Commercial |
$5,367.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,129.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,160.92
|
| Rate for Payer: Cash Price |
$1,789.20
|
| Rate for Payer: Cigna Commercial |
$5,486.88
|
| Rate for Payer: Health EOS Commercial |
$5,307.96
|
| Rate for Payer: HFN Commercial |
$5,486.88
|
| Rate for Payer: Multiplan Commercial |
$4,771.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,578.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,486.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,922.36
|
| Rate for Payer: Quartz Commercial |
$3,578.40
|
| Rate for Payer: WEA Trust Commercial |
$3,280.20
|
| Rate for Payer: WPS Commercial |
$4,417.53
|
|
|
Sedimentation Rate
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
633830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
Sedimentation Rate
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
633830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$100.70 |
| Rate for Payer: Aetna Commercial |
$100.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.60
|
| Rate for Payer: Health EOS Commercial |
$96.46
|
| Rate for Payer: HFN Commercial |
$100.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.53
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: Preferred Network Access Commercial |
$100.70
|
| Rate for Payer: Quartz Beloit One Network |
$46.64
|
| Rate for Payer: Quartz Commercial |
$60.42
|
| Rate for Payer: The Alliance Commercial |
$53.00
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
Sedimentation Rate
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
633830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$2.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.48
|
| Rate for Payer: Anthem Medicaid |
$2.79
|
| Rate for Payer: Anthem Medicare Advantage |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.70
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.32
|
| Rate for Payer: Dean Health Medicaid |
$2.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2.70
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.70
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.70
|
| Rate for Payer: Managed Health Services Medicaid |
$2.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2.70
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$4.05
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2.79
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2.70
|
| Rate for Payer: The Alliance Commercial |
$10.80
|
| Rate for Payer: United Healthcare Medicaid |
$2.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.70
|
| Rate for Payer: United Healthcare PPO |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: Wellcare Medicare |
$2.70
|
| Rate for Payer: WMAP Medicaid |
$2.79
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$53,027.00
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$19,074.49 |
| Max. Negotiated Rate |
$53,027.00 |
| Rate for Payer: Aetna Managed Medicare |
$19,074.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41,540.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31,840.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30,250.44
|
| Rate for Payer: Anthem Medicare Advantage |
$19,074.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,074.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,074.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,074.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,580.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,074.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,658.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,074.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,074.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,074.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,074.49
|
| Rate for Payer: NAPHCARE Commercial |
$28,611.74
|
| Rate for Payer: Quartz Medicare Advantage |
$19,074.49
|
| Rate for Payer: The Alliance Commercial |
$53,027.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,074.49
|
| Rate for Payer: United Healthcare PPO |
$30,096.33
|
| Rate for Payer: Wellcare Medicare |
$19,074.49
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$24,503.00
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$8,814.03 |
| Max. Negotiated Rate |
$24,503.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,814.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,091.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,633.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,902.98
|
| Rate for Payer: Anthem Medicare Advantage |
$8,814.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,814.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,814.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,814.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,433.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,814.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,737.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,814.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,814.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,814.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,814.03
|
| Rate for Payer: NAPHCARE Commercial |
$13,221.04
|
| Rate for Payer: Quartz Medicare Advantage |
$8,814.03
|
| Rate for Payer: The Alliance Commercial |
$24,503.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,814.03
|
| Rate for Payer: United Healthcare PPO |
$13,808.64
|
| Rate for Payer: Wellcare Medicare |
$8,814.03
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 36215
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
|
|
Selenium Level
|
Professional
|
Both
|
$319.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
978063
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.12 |
| Max. Negotiated Rate |
$303.05 |
| Rate for Payer: Aetna Commercial |
$303.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.34
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cigna Commercial |
$303.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$191.40
|
| Rate for Payer: Health EOS Commercial |
$290.29
|
| Rate for Payer: HFN Commercial |
$303.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.12
|
| Rate for Payer: Multiplan Commercial |
$255.20
|
| Rate for Payer: Preferred Network Access Commercial |
$303.05
|
| Rate for Payer: Quartz Beloit One Network |
$140.36
|
| Rate for Payer: Quartz Commercial |
$181.83
|
| Rate for Payer: The Alliance Commercial |
$159.50
|
| Rate for Payer: WEA Trust Commercial |
$175.45
|
| Rate for Payer: WPS Commercial |
$236.28
|
|
|
Selenium Level
|
Facility
|
IP
|
$319.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
978063
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.31 |
| Max. Negotiated Rate |
$293.48 |
| Rate for Payer: Aetna Commercial |
$287.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.07
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cigna Commercial |
$293.48
|
| Rate for Payer: Health EOS Commercial |
$283.91
|
| Rate for Payer: HFN Commercial |
$293.48
|
| Rate for Payer: Multiplan Commercial |
$255.20
|
| Rate for Payer: NAPHCARE Commercial |
$191.40
|
| Rate for Payer: Preferred Network Access Commercial |
$293.48
|
| Rate for Payer: Quartz Beloit One Network |
$156.31
|
| Rate for Payer: Quartz Commercial |
$191.40
|
| Rate for Payer: WEA Trust Commercial |
$175.45
|
| Rate for Payer: WPS Commercial |
$236.28
|
|
|
Selenium Level
|
Facility
|
OP
|
$319.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
978063
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.53 |
| Max. Negotiated Rate |
$293.48 |
| Rate for Payer: Aetna Commercial |
$287.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.34
|
| Rate for Payer: Aetna Managed Medicare |
$25.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.38
|
| Rate for Payer: Anthem Medicaid |
$26.38
|
| Rate for Payer: Anthem Medicare Advantage |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.53
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cigna Commercial |
$293.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.51
|
| Rate for Payer: Dean Health Medicaid |
$26.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.53
|
| Rate for Payer: Health EOS Commercial |
$283.91
|
| Rate for Payer: HFN Commercial |
$293.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.53
|
| Rate for Payer: Managed Health Services Medicaid |
$27.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.53
|
| Rate for Payer: Multiplan Commercial |
$255.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.30
|
| Rate for Payer: Preferred Network Access Commercial |
$293.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.38
|
| Rate for Payer: Quartz Beloit One Network |
$156.31
|
| Rate for Payer: Quartz Commercial |
$207.35
|
| Rate for Payer: Quartz Medicare Advantage |
$25.53
|
| Rate for Payer: The Alliance Commercial |
$102.12
|
| Rate for Payer: United Healthcare Medicaid |
$26.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.53
|
| Rate for Payer: United Healthcare PPO |
$239.25
|
| Rate for Payer: WEA Trust Commercial |
$175.45
|
| Rate for Payer: Wellcare Medicare |
$25.53
|
| Rate for Payer: WMAP Medicaid |
$26.38
|
| Rate for Payer: WPS Commercial |
$236.28
|
|
|
Self-Mgmt Educ & Train 1 Pt
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 98960
|
| Hospital Charge Code |
4668607
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Self-Mgmt Educ & Train 1 Pt
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 98960
|
| Hospital Charge Code |
4668607
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$688.00 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.25
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: The Alliance Commercial |
$688.00
|
| Rate for Payer: United Healthcare PPO |
$129.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Semen Analysis Complete
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
CPT 89320
|
| Hospital Charge Code |
633831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.58 |
| Max. Negotiated Rate |
$222.64 |
| Rate for Payer: Aetna Commercial |
$217.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.26
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$222.64
|
| Rate for Payer: Health EOS Commercial |
$215.38
|
| Rate for Payer: HFN Commercial |
$222.64
|
| Rate for Payer: Multiplan Commercial |
$193.60
|
| Rate for Payer: NAPHCARE Commercial |
$145.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.64
|
| Rate for Payer: Quartz Beloit One Network |
$118.58
|
| Rate for Payer: Quartz Commercial |
$145.20
|
| Rate for Payer: WEA Trust Commercial |
$133.10
|
| Rate for Payer: WPS Commercial |
$179.25
|
|
|
Semen Analysis Complete
|
Professional
|
Both
|
$242.00
|
|
|
Service Code
|
CPT 89320
|
| Hospital Charge Code |
633831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.45 |
| Max. Negotiated Rate |
$229.90 |
| Rate for Payer: Aetna Commercial |
$229.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.12
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$229.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.20
|
| Rate for Payer: Health EOS Commercial |
$220.22
|
| Rate for Payer: HFN Commercial |
$229.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.45
|
| Rate for Payer: Multiplan Commercial |
$193.60
|
| Rate for Payer: Preferred Network Access Commercial |
$229.90
|
| Rate for Payer: Quartz Beloit One Network |
$106.48
|
| Rate for Payer: Quartz Commercial |
$137.94
|
| Rate for Payer: The Alliance Commercial |
$121.00
|
| Rate for Payer: WEA Trust Commercial |
$133.10
|
| Rate for Payer: WPS Commercial |
$179.25
|
|
|
Semen Analysis Complete
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
CPT 89320
|
| Hospital Charge Code |
633831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$222.64 |
| Rate for Payer: Aetna Commercial |
$217.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.12
|
| Rate for Payer: Aetna Managed Medicare |
$12.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.43
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.31
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$222.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.42
|
| Rate for Payer: Dean Health Medicaid |
$12.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$215.38
|
| Rate for Payer: HFN Commercial |
$222.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.31
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.31
|
| Rate for Payer: Managed Health Services Medicaid |
$13.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.31
|
| Rate for Payer: Multiplan Commercial |
$193.60
|
| Rate for Payer: NAPHCARE Commercial |
$18.46
|
| Rate for Payer: Preferred Network Access Commercial |
$222.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.58
|
| Rate for Payer: Quartz Commercial |
$157.30
|
| Rate for Payer: Quartz Medicare Advantage |
$12.31
|
| Rate for Payer: The Alliance Commercial |
$49.24
|
| Rate for Payer: United Healthcare Medicaid |
$12.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.31
|
| Rate for Payer: United Healthcare PPO |
$181.50
|
| Rate for Payer: WEA Trust Commercial |
$133.10
|
| Rate for Payer: Wellcare Medicare |
$12.31
|
| Rate for Payer: WMAP Medicaid |
$12.72
|
| Rate for Payer: WPS Commercial |
$179.25
|
|
