|
COMPLICATED PEPTIC ULCER WITH MCC
|
Facility
|
IP
|
$54,207.92
|
|
|
Service Code
|
MSDRG 380
|
| Min. Negotiated Rate |
$15,533.69 |
| Max. Negotiated Rate |
$54,207.92 |
| Rate for Payer: Aetna Managed Medicare |
$15,533.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42,813.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32,816.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31,177.63
|
| Rate for Payer: Anthem Medicare Advantage |
$15,533.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,533.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,533.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,533.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34,610.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,533.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,515.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,533.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,533.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,533.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,533.69
|
| Rate for Payer: NAPHCARE Commercial |
$23,300.53
|
| Rate for Payer: Quartz Medicare Advantage |
$15,533.69
|
| Rate for Payer: The Alliance Commercial |
$54,207.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,533.69
|
| Rate for Payer: United Healthcare PPO |
$30,763.39
|
| Rate for Payer: Wellcare Medicare |
$15,533.69
|
|
|
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC
|
Facility
|
IP
|
$21,266.96
|
|
|
Service Code
|
MSDRG 382
|
| Min. Negotiated Rate |
$6,637.94 |
| Max. Negotiated Rate |
$21,266.96 |
| Rate for Payer: Aetna Managed Medicare |
$6,637.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,468.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,389.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,720.83
|
| Rate for Payer: Anthem Medicare Advantage |
$6,637.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,637.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,637.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,637.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,121.29
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,637.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,353.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,637.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,637.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,637.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,637.94
|
| Rate for Payer: NAPHCARE Commercial |
$9,956.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,637.94
|
| Rate for Payer: The Alliance Commercial |
$21,266.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,637.94
|
| Rate for Payer: United Healthcare PPO |
$11,953.28
|
| Rate for Payer: Wellcare Medicare |
$6,637.94
|
|
|
COMPLICATIONS OF TREATMENT AFFECTING PREGNANCY
|
Facility
|
OP
|
$99.58
|
|
|
Service Code
|
EAPG 00767
|
| Min. Negotiated Rate |
$95.75 |
| Max. Negotiated Rate |
$99.58 |
| Rate for Payer: Anthem Medicaid |
$95.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$95.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.75
|
| Rate for Payer: Dean Health Medicaid |
$95.75
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$95.75
|
| Rate for Payer: Managed Health Services Medicaid |
$99.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.75
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$95.75
|
| Rate for Payer: United Healthcare Medicaid |
$95.75
|
|
|
COMPLICATIONS OF TREATMENT WITH CC
|
Facility
|
IP
|
$28,917.20
|
|
|
Service Code
|
MSDRG 920
|
| Min. Negotiated Rate |
$8,182.60 |
| Max. Negotiated Rate |
$28,917.20 |
| Rate for Payer: Aetna Managed Medicare |
$8,182.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,869.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,762.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,925.66
|
| Rate for Payer: Anthem Medicare Advantage |
$8,182.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,182.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,182.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,182.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,678.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,182.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,965.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,182.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,182.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,182.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,182.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,273.89
|
| Rate for Payer: Quartz Medicare Advantage |
$8,182.60
|
| Rate for Payer: The Alliance Commercial |
$28,917.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,182.60
|
| Rate for Payer: United Healthcare PPO |
$16,321.88
|
| Rate for Payer: Wellcare Medicare |
$8,182.60
|
|
|
COMPLICATIONS OF TREATMENT WITH MCC
|
Facility
|
IP
|
$50,785.28
|
|
|
Service Code
|
MSDRG 919
|
| Min. Negotiated Rate |
$14,527.41 |
| Max. Negotiated Rate |
$50,785.28 |
| Rate for Payer: Aetna Managed Medicare |
$14,527.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,946.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,618.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29,089.80
|
| Rate for Payer: Anthem Medicare Advantage |
$14,527.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,527.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,527.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,527.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32,292.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,527.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,004.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,527.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,527.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,527.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,527.41
|
| Rate for Payer: NAPHCARE Commercial |
$21,791.11
|
| Rate for Payer: Quartz Medicare Advantage |
$14,527.41
|
| Rate for Payer: The Alliance Commercial |
$50,785.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,527.41
|
| Rate for Payer: United Healthcare PPO |
$28,808.80
|
| Rate for Payer: Wellcare Medicare |
$14,527.41
|
|
|
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$19,626.88
|
|
|
Service Code
|
MSDRG 921
|
| Min. Negotiated Rate |
$5,778.67 |
| Max. Negotiated Rate |
$19,626.88 |
| Rate for Payer: Aetna Managed Medicare |
$5,778.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,020.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,512.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,938.07
|
| Rate for Payer: Anthem Medicare Advantage |
$5,778.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,778.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,778.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,778.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,142.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,778.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,151.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,778.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,778.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,778.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,778.67
|
| Rate for Payer: NAPHCARE Commercial |
$8,668.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,778.67
|
| Rate for Payer: The Alliance Commercial |
$19,626.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,778.67
|
| Rate for Payer: United Healthcare PPO |
$11,017.03
|
| Rate for Payer: Wellcare Medicare |
$5,778.67
|
|
|
COMPONENT ARTICULAR 15MM 9152-2040-W
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 15MM 9152-2040-W
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-1525
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-1525
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-2030
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-2030
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-2535
|
Facility
|
OP
|
$12,202.00
|
|
| Hospital Charge Code |
2964727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT ARTICULAR 9152-2535
|
Facility
|
IP
|
$12,202.00
|
|
| Hospital Charge Code |
2964727
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
COMPONENT FEM C-LT FLEX CR PRECOAT 5950-13-01
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967640
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-LT FLEX CR PRECOAT 5950-13-01
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967640
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-LT GSF CR FLEX 00-5750-013-01
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM C-LT GSF CR FLEX 00-5750-013-01
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967641
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM C-MINUS LT FLEX CR 5950-13-05
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-MINUS LT FLEX CR 5950-13-05
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-MINUS LT GSF FLEX CR 00-5750-013-05
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM C-MINUS LT GSF FLEX CR 00-5750-013-05
|
Facility
|
OP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967643
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,232.57 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Aetna Managed Medicare |
$5,232.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,147.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,343.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,970.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,457.96
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,015.82
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: NAPHCARE Commercial |
$11,212.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$12,147.04
|
| Rate for Payer: Quartz Medicare Advantage |
$11,212.66
|
| Rate for Payer: The Alliance Commercial |
$9,343.88
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
|
COMPONENT FEM C-MINUS RT FLEX CR 5950-13-06
|
Facility
|
IP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,478.56 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$11,606.40
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-MINUS RT FLEX CR 5950-13-06
|
Facility
|
OP
|
$18,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967644
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,416.32 |
| Max. Negotiated Rate |
$17,796.48 |
| Rate for Payer: Aetna Commercial |
$17,409.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,635.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,416.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,573.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,672.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,285.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,252.32
|
| Rate for Payer: Cash Price |
$5,580.00
|
| Rate for Payer: Cigna Commercial |
$17,796.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,825.20
|
| Rate for Payer: Health EOS Commercial |
$17,216.16
|
| Rate for Payer: HFN Commercial |
$17,796.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,508.00
|
| Rate for Payer: Multiplan Commercial |
$15,475.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,606.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,796.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,478.56
|
| Rate for Payer: Quartz Commercial |
$12,573.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,606.40
|
| Rate for Payer: The Alliance Commercial |
$9,672.00
|
| Rate for Payer: WEA Trust Commercial |
$10,639.20
|
| Rate for Payer: WPS Commercial |
$14,327.58
|
|
|
COMPONENT FEM C-MINUS RT GSF FLEX CR 00-5750-013-06
|
Facility
|
IP
|
$17,969.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967645
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,157.00 |
| Max. Negotiated Rate |
$17,192.74 |
| Rate for Payer: Aetna Commercial |
$16,818.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,071.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,904.51
|
| Rate for Payer: Cash Price |
$5,390.70
|
| Rate for Payer: Cigna Commercial |
$17,192.74
|
| Rate for Payer: Health EOS Commercial |
$16,632.11
|
| Rate for Payer: HFN Commercial |
$17,192.74
|
| Rate for Payer: Multiplan Commercial |
$14,950.21
|
| Rate for Payer: Preferred Network Access Commercial |
$17,192.74
|
| Rate for Payer: Quartz Beloit One Network |
$9,157.00
|
| Rate for Payer: Quartz Commercial |
$11,212.66
|
| Rate for Payer: WEA Trust Commercial |
$10,278.27
|
| Rate for Payer: WPS Commercial |
$13,841.52
|
|
