|
BUTTON OLYMPUS BIPOLAR HF 12/30 DEG WA22760S/WA22557C
|
Facility
OP
|
$5,794.00
|
|
| Hospital Charge Code |
4510815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,622.32 |
| Max. Negotiated Rate |
$23,176.00 |
| Rate for Payer: Aetna Commercial |
$5,214.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,982.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,622.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,766.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,897.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,781.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,070.82
|
| Rate for Payer: Cash Price |
$1,738.20
|
| Rate for Payer: Cigna Commercial |
$5,330.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,242.32
|
| Rate for Payer: Health EOS Commercial |
$5,156.66
|
| Rate for Payer: HFN Commercial |
$5,330.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,345.50
|
| Rate for Payer: Multiplan Commercial |
$4,635.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,476.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,330.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,839.06
|
| Rate for Payer: Quartz Commercial |
$3,766.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,476.40
|
| Rate for Payer: The Alliance Commercial |
$23,176.00
|
| Rate for Payer: WEA Trust Commercial |
$3,186.70
|
| Rate for Payer: WPS Commercial |
$4,291.62
|
|
|
BX BREAST PERCUT W/IMAGE 19102
|
Professional
|
$1,076.00
|
|
| Hospital Charge Code |
3013677
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$473.44 |
| Max. Negotiated Rate |
$1,022.20 |
| Rate for Payer: Aetna Commercial |
$1,022.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.36
|
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$1,022.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$538.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$645.60
|
| Rate for Payer: Health EOS Commercial |
$979.16
|
| Rate for Payer: Multiplan Commercial |
$860.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,022.20
|
| Rate for Payer: Quartz Beloit One Network |
$473.44
|
| Rate for Payer: Quartz Commercial |
$613.32
|
| Rate for Payer: The Alliance Commercial |
$538.00
|
| Rate for Payer: WEA Trust Commercial |
$591.80
|
| Rate for Payer: WPS Commercial |
$796.99
|
|
|
BX BREAST PERCUT W/O IMAGE 19100
|
Professional
|
$595.00
|
|
|
Service Code
|
CPT 19100
|
| Hospital Charge Code |
3013675
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$565.25 |
| Rate for Payer: Aetna Commercial |
$565.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$511.70
|
| Rate for Payer: Aetna Managed Medicare |
$61.68
|
| Rate for Payer: Anthem Medicare Advantage |
$61.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$61.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$61.68
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cigna Commercial |
$565.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$297.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.68
|
| Rate for Payer: Health EOS Commercial |
$541.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$223.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$61.68
|
| Rate for Payer: Multiplan Commercial |
$476.00
|
| Rate for Payer: Preferred Network Access Commercial |
$565.25
|
| Rate for Payer: Quartz Beloit One Network |
$261.80
|
| Rate for Payer: Quartz Commercial |
$339.15
|
| Rate for Payer: Quartz Medicare Advantage |
$61.68
|
| Rate for Payer: The Alliance Commercial |
$262.14
|
| Rate for Payer: United Healthcare Medicaid |
$57.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.68
|
| Rate for Payer: WEA Trust Commercial |
$327.25
|
| Rate for Payer: WPS Commercial |
$277.56
|
|
|
BX Breast w/Device addl Lesion Ultrasound 19084
|
Professional
|
$2,494.00
|
|
|
Service Code
|
CPT 19084
|
| Hospital Charge Code |
4586627
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.82 |
| Max. Negotiated Rate |
$2,369.30 |
| Rate for Payer: Aetna Commercial |
$2,369.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,144.84
|
| Rate for Payer: Aetna Managed Medicare |
$72.68
|
| Rate for Payer: Anthem Medicare Advantage |
$72.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.68
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cigna Commercial |
$2,369.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,247.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$2,269.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$261.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$1,995.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,369.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,097.36
|
| Rate for Payer: Quartz Commercial |
$1,421.58
|
| Rate for Payer: Quartz Medicare Advantage |
$72.68
|
| Rate for Payer: The Alliance Commercial |
$308.89
|
| Rate for Payer: United Healthcare Medicaid |
$59.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.68
|
| Rate for Payer: WEA Trust Commercial |
$1,371.70
|
| Rate for Payer: WPS Commercial |
$327.06
|
|
|
BX Done W/Colposcopy Add-On 58110
|
Professional
|
$89.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
3867360
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$166.64 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$37.03
|
| Rate for Payer: Anthem Medicare Advantage |
$37.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.03
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.03
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.03
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: Quartz Medicare Advantage |
$37.03
|
| Rate for Payer: The Alliance Commercial |
$157.38
|
| Rate for Payer: United Healthcare Medicaid |
$44.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.03
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$166.64
|
|
|
C02/membane diffuse capacity 9472926
|
Professional
|
$113.00
|
|
|
Service Code
|
CPT 94729 26
|
| Hospital Charge Code |
3015459
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$107.35 |
| Rate for Payer: Aetna Commercial |
$107.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97.18
|
| Rate for Payer: Aetna Managed Medicare |
$8.48
|
| Rate for Payer: Anthem Medicare Advantage |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.48
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$107.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.48
|
| Rate for Payer: Health EOS Commercial |
$102.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$90.40
|
| Rate for Payer: Preferred Network Access Commercial |
$107.35
|
| Rate for Payer: Quartz Beloit One Network |
$49.72
|
| Rate for Payer: Quartz Commercial |
$64.41
|
| Rate for Payer: Quartz Medicare Advantage |
$8.48
|
| Rate for Payer: The Alliance Commercial |
$21.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.48
|
| Rate for Payer: WEA Trust Commercial |
$62.15
|
| Rate for Payer: WPS Commercial |
$33.92
|
|
|
C1 Esterase Inhibitor Protein
|
Facility
OP
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$275.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$263.16
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$281.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$272.34
|
| Rate for Payer: HFN Commercial |
$281.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$244.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$281.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$149.94
|
| Rate for Payer: Quartz Commercial |
$198.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$229.50
|
| Rate for Payer: WEA Trust Commercial |
$168.30
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$226.65
|
|
|
C1 Esterase Inhibitor Protein
|
Professional
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Aetna Commercial |
$290.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$263.16
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$290.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$153.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$278.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$244.80
|
| Rate for Payer: Preferred Network Access Commercial |
$290.70
|
| Rate for Payer: Quartz Beloit One Network |
$134.64
|
| Rate for Payer: Quartz Commercial |
$174.42
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$168.30
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C1 Esterase Inhibitor Protein
|
Facility
IP
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.94 |
| Max. Negotiated Rate |
$281.52 |
| Rate for Payer: Aetna Commercial |
$275.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.18
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$281.52
|
| Rate for Payer: Health EOS Commercial |
$272.34
|
| Rate for Payer: HFN Commercial |
$281.52
|
| Rate for Payer: Multiplan Commercial |
$244.80
|
| Rate for Payer: NAPHCARE Commercial |
$183.60
|
| Rate for Payer: Preferred Network Access Commercial |
$281.52
|
| Rate for Payer: Quartz Beloit One Network |
$149.94
|
| Rate for Payer: Quartz Commercial |
$183.60
|
| Rate for Payer: WEA Trust Commercial |
$168.30
|
| Rate for Payer: WPS Commercial |
$226.65
|
|
|
C1 Inhibitor Functional
|
Professional
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Aetna Commercial |
$66.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$63.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: Preferred Network Access Commercial |
$66.50
|
| Rate for Payer: Quartz Beloit One Network |
$30.80
|
| Rate for Payer: Quartz Commercial |
$39.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C1 Inhibitor Functional
|
Facility
OP
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
C1 Inhibitor Functional
|
Facility
IP
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
C2 Complement
|
Facility
IP
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$216.20 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$141.00
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$141.00
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
C2 Complement
|
Professional
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna Commercial |
$223.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$223.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$213.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: Preferred Network Access Commercial |
$223.25
|
| Rate for Payer: Quartz Beloit One Network |
$103.40
|
| Rate for Payer: Quartz Commercial |
$133.95
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C2 Complement
|
Facility
OP
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$152.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$940.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$176.25
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
C3 Complement
|
Facility
IP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$142.80
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
C3 Complement
|
Professional
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna Commercial |
$209.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$209.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$200.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: Preferred Network Access Commercial |
$209.00
|
| Rate for Payer: Quartz Beloit One Network |
$96.80
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C3 Complement
|
Facility
OP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$952.00 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$154.70
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$178.50
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
C3 Complement
|
Professional
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$226.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$216.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: Preferred Network Access Commercial |
$226.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.72
|
| Rate for Payer: Quartz Commercial |
$135.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C3 Complement
|
Facility
OP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$143.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$880.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
C3 Complement
|
Facility
IP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
C4a Level
|
Professional
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Aetna Commercial |
$106.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$106.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$101.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: Preferred Network Access Commercial |
$106.40
|
| Rate for Payer: Quartz Beloit One Network |
$49.28
|
| Rate for Payer: Quartz Commercial |
$63.84
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C4a Level
|
Facility
OP
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$448.00 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$72.80
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$448.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
C4a Level
|
Facility
IP
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$103.04 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$67.20
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
C4 Complement
|
Professional
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna Commercial |
$209.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$209.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$200.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: Preferred Network Access Commercial |
$209.00
|
| Rate for Payer: Quartz Beloit One Network |
$96.80
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
