|
TSII-Protein C Activity
|
Facility
|
OP
|
$283.00
|
|
|
Service Code
|
CPT 85303
|
| Hospital Charge Code |
4066517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$270.77 |
| Rate for Payer: Aetna Commercial |
$264.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$253.12
|
| Rate for Payer: Aetna Managed Medicare |
$14.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.89
|
| Rate for Payer: Anthem Medicare Advantage |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.39
|
| Rate for Payer: Cash Price |
$84.90
|
| Rate for Payer: Cash Price |
$84.90
|
| Rate for Payer: Cigna Commercial |
$270.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$164.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.39
|
| Rate for Payer: Health EOS Commercial |
$261.94
|
| Rate for Payer: HFN Commercial |
$270.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.39
|
| Rate for Payer: Multiplan Commercial |
$235.46
|
| Rate for Payer: NAPHCARE Commercial |
$21.59
|
| Rate for Payer: Preferred Network Access Commercial |
$270.77
|
| Rate for Payer: Quartz Beloit One Network |
$144.22
|
| Rate for Payer: Quartz Commercial |
$191.31
|
| Rate for Payer: Quartz Medicare Advantage |
$14.39
|
| Rate for Payer: The Alliance Commercial |
$57.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.39
|
| Rate for Payer: United Healthcare PPO |
$220.74
|
| Rate for Payer: WEA Trust Commercial |
$161.88
|
| Rate for Payer: Wellcare Medicare |
$14.39
|
| Rate for Payer: WPS Commercial |
$217.99
|
|
|
TSII-Protein C Activity
|
Professional
|
Both
|
$283.00
|
|
|
Service Code
|
CPT 85303
|
| Hospital Charge Code |
4066517
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$279.60 |
| Rate for Payer: Aetna Commercial |
$279.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$253.12
|
| Rate for Payer: Aetna Managed Medicare |
$14.39
|
| Rate for Payer: Anthem Medicare Advantage |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.39
|
| Rate for Payer: Cash Price |
$84.90
|
| Rate for Payer: Cash Price |
$84.90
|
| Rate for Payer: Cigna Commercial |
$279.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$147.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.39
|
| Rate for Payer: Health EOS Commercial |
$267.83
|
| Rate for Payer: HFN Commercial |
$279.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.39
|
| Rate for Payer: Multiplan Commercial |
$235.46
|
| Rate for Payer: NAPHCARE Commercial |
$21.59
|
| Rate for Payer: Preferred Network Access Commercial |
$279.60
|
| Rate for Payer: Quartz Beloit One Network |
$129.50
|
| Rate for Payer: Quartz Commercial |
$167.76
|
| Rate for Payer: Quartz Medicare Advantage |
$14.39
|
| Rate for Payer: The Alliance Commercial |
$56.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.39
|
| Rate for Payer: WEA Trust Commercial |
$161.88
|
| Rate for Payer: WPS Commercial |
$63.33
|
|
|
TSII-Protein S Antigen, Free
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 85306
|
| Hospital Charge Code |
4066518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.43 |
| Max. Negotiated Rate |
$192.32 |
| Rate for Payer: Aetna Commercial |
$188.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.79
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cigna Commercial |
$192.32
|
| Rate for Payer: Health EOS Commercial |
$186.05
|
| Rate for Payer: HFN Commercial |
$192.32
|
| Rate for Payer: Multiplan Commercial |
$167.23
|
| Rate for Payer: Preferred Network Access Commercial |
$192.32
|
| Rate for Payer: Quartz Beloit One Network |
$102.43
|
| Rate for Payer: Quartz Commercial |
$125.42
|
| Rate for Payer: WEA Trust Commercial |
$114.97
|
| Rate for Payer: WPS Commercial |
$154.83
|
|
|
TSII-Protein S Antigen, Free
|
Professional
|
Both
|
$201.00
|
|
|
Service Code
|
CPT 85306
|
| Hospital Charge Code |
4066518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$198.59 |
| Rate for Payer: Aetna Commercial |
$198.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.77
|
| Rate for Payer: Aetna Managed Medicare |
$15.93
|
| Rate for Payer: Anthem Medicare Advantage |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.93
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cigna Commercial |
$198.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.93
|
| Rate for Payer: Health EOS Commercial |
$190.23
|
| Rate for Payer: HFN Commercial |
$198.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.93
|
| Rate for Payer: Multiplan Commercial |
$167.23
|
| Rate for Payer: NAPHCARE Commercial |
$23.90
|
| Rate for Payer: Preferred Network Access Commercial |
$198.59
|
| Rate for Payer: Quartz Beloit One Network |
$91.98
|
| Rate for Payer: Quartz Commercial |
$119.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15.93
|
| Rate for Payer: The Alliance Commercial |
$62.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.93
|
| Rate for Payer: WEA Trust Commercial |
$114.97
|
| Rate for Payer: WPS Commercial |
$70.10
|
|
|
TSII-Protein S Antigen, Free
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 85306
|
| Hospital Charge Code |
4066518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$192.32 |
| Rate for Payer: Aetna Commercial |
$188.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.77
|
| Rate for Payer: Aetna Managed Medicare |
$15.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.45
|
| Rate for Payer: Anthem Medicare Advantage |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.93
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: Cigna Commercial |
$192.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.93
|
| Rate for Payer: Health EOS Commercial |
$186.05
|
| Rate for Payer: HFN Commercial |
$192.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.93
|
| Rate for Payer: Multiplan Commercial |
$167.23
|
| Rate for Payer: NAPHCARE Commercial |
$23.90
|
| Rate for Payer: Preferred Network Access Commercial |
$192.32
|
| Rate for Payer: Quartz Beloit One Network |
$102.43
|
| Rate for Payer: Quartz Commercial |
$135.88
|
| Rate for Payer: Quartz Medicare Advantage |
$15.93
|
| Rate for Payer: The Alliance Commercial |
$63.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.93
|
| Rate for Payer: United Healthcare PPO |
$156.78
|
| Rate for Payer: WEA Trust Commercial |
$114.97
|
| Rate for Payer: Wellcare Medicare |
$15.93
|
| Rate for Payer: WPS Commercial |
$154.83
|
|
|
T-TUBE 10 FRENCH
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2975043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 10 FRENCH
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2975043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 12 FRENCH SU130-1238
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2975042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 12 FRENCH SU130-1238
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2975042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 14 FRENCH
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2963378
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 14 FRENCH
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2963378
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 16 FRENCH SU130-1240
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2963377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 16 FRENCH SU130-1240
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2963377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 20 FRENCH
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
2963379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
T-TUBE 20 FRENCH
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
2963379
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
TUBAL LIGATION, POST PARTUM
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960319
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TUBAL LIGATION, POST PARTUM
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960319
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TUBE 2 WAY FLUID ADM. SET
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
2963350
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
TUBE 2 WAY FLUID ADM. SET
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
2963350
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
TUBE BLAKEMORE ESOPH NASOGAS
|
Facility
|
OP
|
$3,091.00
|
|
| Hospital Charge Code |
2962942
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$900.10 |
| Max. Negotiated Rate |
$2,957.47 |
| Rate for Payer: Aetna Commercial |
$2,893.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,764.59
|
| Rate for Payer: Aetna Managed Medicare |
$900.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,089.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,607.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,543.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,703.76
|
| Rate for Payer: Cash Price |
$927.30
|
| Rate for Payer: Cigna Commercial |
$2,957.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,798.96
|
| Rate for Payer: Health EOS Commercial |
$2,861.03
|
| Rate for Payer: HFN Commercial |
$2,957.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,410.98
|
| Rate for Payer: Multiplan Commercial |
$2,571.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,928.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,957.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,575.17
|
| Rate for Payer: Quartz Commercial |
$2,089.52
|
| Rate for Payer: Quartz Medicare Advantage |
$1,928.78
|
| Rate for Payer: The Alliance Commercial |
$1,607.32
|
| Rate for Payer: WEA Trust Commercial |
$1,768.05
|
| Rate for Payer: WPS Commercial |
$2,381.00
|
|
|
TUBE BLAKEMORE ESOPH NASOGAS
|
Facility
|
IP
|
$3,091.00
|
|
| Hospital Charge Code |
2962942
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,575.17 |
| Max. Negotiated Rate |
$2,957.47 |
| Rate for Payer: Aetna Commercial |
$2,893.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,764.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,703.76
|
| Rate for Payer: Cash Price |
$927.30
|
| Rate for Payer: Cigna Commercial |
$2,957.47
|
| Rate for Payer: Health EOS Commercial |
$2,861.03
|
| Rate for Payer: HFN Commercial |
$2,957.47
|
| Rate for Payer: Multiplan Commercial |
$2,571.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,957.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,575.17
|
| Rate for Payer: Quartz Commercial |
$1,928.78
|
| Rate for Payer: WEA Trust Commercial |
$1,768.05
|
| Rate for Payer: WPS Commercial |
$2,381.00
|
|
|
TUBE BRONCH RUSCH DBL LMN LT 35FR #116100035
|
Facility
|
IP
|
$1,023.00
|
|
| Hospital Charge Code |
2974654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.32 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$638.35
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
TUBE BRONCH RUSCH DBL LMN LT 35FR #116100035
|
Facility
|
OP
|
$1,023.00
|
|
| Hospital Charge Code |
2974654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$978.81 |
| Rate for Payer: Aetna Commercial |
$957.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.97
|
| Rate for Payer: Aetna Managed Medicare |
$297.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$691.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$531.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$510.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$563.88
|
| Rate for Payer: Cash Price |
$306.90
|
| Rate for Payer: Cigna Commercial |
$978.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$595.39
|
| Rate for Payer: Health EOS Commercial |
$946.89
|
| Rate for Payer: HFN Commercial |
$978.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$797.94
|
| Rate for Payer: Multiplan Commercial |
$851.14
|
| Rate for Payer: NAPHCARE Commercial |
$638.35
|
| Rate for Payer: Preferred Network Access Commercial |
$978.81
|
| Rate for Payer: Quartz Beloit One Network |
$521.32
|
| Rate for Payer: Quartz Commercial |
$691.55
|
| Rate for Payer: Quartz Medicare Advantage |
$638.35
|
| Rate for Payer: The Alliance Commercial |
$531.96
|
| Rate for Payer: WEA Trust Commercial |
$585.16
|
| Rate for Payer: WPS Commercial |
$788.02
|
|
|
Tube-Cont-Flo Adm
|
Facility
|
OP
|
$152.00
|
|
| Hospital Charge Code |
3101774
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.26 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Aetna Managed Medicare |
$44.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.46
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.56
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: NAPHCARE Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$102.75
|
| Rate for Payer: Quartz Medicare Advantage |
$94.85
|
| Rate for Payer: The Alliance Commercial |
$79.04
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
Tube-Cont-Flo Adm
|
Facility
|
IP
|
$152.00
|
|
| Hospital Charge Code |
3101774
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.46 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
