|
Dianeal 2L 4.25% Ultrabag, Low
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
HCPCS A4722
|
| Hospital Charge Code |
3603557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
DIAPERS PREM 3-6 LB INFANT 04261
|
Facility
IP
|
$81.00
|
|
| Hospital Charge Code |
2963729
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
DIAPERS PREM 3-6 LB INFANT 04261
|
Facility
OP
|
$81.00
|
|
| Hospital Charge Code |
2963729
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
DIAPERS SIZE 3 STRETCH
|
Facility
IP
|
$135.00
|
|
| Hospital Charge Code |
2963801
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$124.20 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$81.00
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$99.99
|
|
|
DIAPERS SIZE 3 STRETCH
|
Facility
OP
|
$135.00
|
|
| Hospital Charge Code |
2963801
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.10
|
| Rate for Payer: Aetna Managed Medicare |
$37.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.55
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.25
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$81.00
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$87.75
|
| Rate for Payer: Quartz Medicare Advantage |
$81.00
|
| Rate for Payer: The Alliance Commercial |
$540.00
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$99.99
|
|
|
DIAPERS SIZE 4 STRETCH
|
Facility
IP
|
$92.00
|
|
| Hospital Charge Code |
2964012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
DIAPERS SIZE 4 STRETCH
|
Facility
OP
|
$92.00
|
|
| Hospital Charge Code |
2964012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$25.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$55.20
|
| Rate for Payer: The Alliance Commercial |
$368.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
DIAPERS SML SZ 1 ULT DRY THIN
|
Facility
IP
|
$81.00
|
|
| Hospital Charge Code |
2963770
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
DIAPERS SML SZ 1 ULT DRY THIN
|
Facility
OP
|
$81.00
|
|
| Hospital Charge Code |
2963770
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Diazepam 10mg/2ml syringe [MED]
|
Facility
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
2983116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$5,847.56 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.38
|
| Rate for Payer: Aetna Managed Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.75
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$21.45
|
| Rate for Payer: Quartz Medicare Advantage |
$19.80
|
| Rate for Payer: The Alliance Commercial |
$5,847.56
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$16.35
|
|
|
Diazepam 10mg/2ml syringe [MED]
|
Facility
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
2983116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$30.36 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$19.80
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$24.44
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Professional
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Diazepam JW Waste Charge per 0.5 mg
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
HCPCS J3360 JW
|
| Hospital Charge Code |
5266697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
Different Drug Addíl IV Push 96375 - Admin Each Add'l IV Push Charge
|
Facility
IP
|
$187.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
3023768
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$91.63 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$112.20
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Different Drug Addíl IV Push 96375 - Admin Each Add'l IV Push Charge
|
Facility
OP
|
$187.00
|
|
|
Service Code
|
CPT 96375
|
| Hospital Charge Code |
3023768
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$46.95 |
| Max. Negotiated Rate |
$174.65 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$121.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.76
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$140.25
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Diffusion Capacity - Pulmonary Function Test Charge
|
Facility
IP
|
$675.00
|
|
|
Service Code
|
CPT 94729
|
| Hospital Charge Code |
3006997
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$330.75 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Aetna Commercial |
$607.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.75
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$621.00
|
| Rate for Payer: Health EOS Commercial |
$600.75
|
| Rate for Payer: HFN Commercial |
$621.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: NAPHCARE Commercial |
$405.00
|
| Rate for Payer: Preferred Network Access Commercial |
$621.00
|
| Rate for Payer: Quartz Beloit One Network |
$330.75
|
| Rate for Payer: Quartz Commercial |
$405.00
|
| Rate for Payer: WEA Trust Commercial |
$371.25
|
| Rate for Payer: WPS Commercial |
$499.97
|
|
|
Diffusion Capacity - Pulmonary Function Test Charge
|
Facility
OP
|
$675.00
|
|
|
Service Code
|
CPT 94729
|
| Hospital Charge Code |
3006997
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Aetna Commercial |
$607.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$580.50
|
| Rate for Payer: Aetna Managed Medicare |
$189.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$438.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$337.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$324.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.75
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$621.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$377.73
|
| Rate for Payer: Health EOS Commercial |
$600.75
|
| Rate for Payer: HFN Commercial |
$621.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$506.25
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: NAPHCARE Commercial |
$405.00
|
| Rate for Payer: Preferred Network Access Commercial |
$621.00
|
| Rate for Payer: Quartz Beloit One Network |
$330.75
|
| Rate for Payer: Quartz Commercial |
$438.75
|
| Rate for Payer: Quartz Medicare Advantage |
$405.00
|
| Rate for Payer: United Healthcare PPO |
$506.25
|
| Rate for Payer: WEA Trust Commercial |
$371.25
|
| Rate for Payer: WPS Commercial |
$499.97
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
IP
|
$32,178.00
|
|
|
Service Code
|
MS-DRG 375
|
| Min. Negotiated Rate |
$11,574.97 |
| Max. Negotiated Rate |
$32,178.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,574.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,176.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,297.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,333.60
|
| Rate for Payer: Anthem Medicare Advantage |
$11,574.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,574.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,574.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,574.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,351.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,574.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,366.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,574.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,574.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,574.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,574.97
|
| Rate for Payer: NAPHCARE Commercial |
$17,362.46
|
| Rate for Payer: Quartz Medicare Advantage |
$11,574.97
|
| Rate for Payer: The Alliance Commercial |
$32,178.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,574.97
|
| Rate for Payer: United Healthcare PPO |
$18,191.39
|
| Rate for Payer: Wellcare Medicare |
$11,574.97
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
IP
|
$56,124.00
|
|
|
Service Code
|
MS-DRG 374
|
| Min. Negotiated Rate |
$20,188.62 |
| Max. Negotiated Rate |
$56,124.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,188.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,058.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33,770.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,083.80
|
| Rate for Payer: Anthem Medicare Advantage |
$20,188.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,188.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,188.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,188.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,615.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,188.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,930.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,188.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,188.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,188.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,188.62
|
| Rate for Payer: NAPHCARE Commercial |
$30,282.93
|
| Rate for Payer: Quartz Medicare Advantage |
$20,188.62
|
| Rate for Payer: The Alliance Commercial |
$56,124.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,188.62
|
| Rate for Payer: United Healthcare PPO |
$31,864.92
|
| Rate for Payer: Wellcare Medicare |
$20,188.62
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
IP
|
$24,019.00
|
|
|
Service Code
|
MS-DRG 376
|
| Min. Negotiated Rate |
$8,639.99 |
| Max. Negotiated Rate |
$24,019.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,639.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,672.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,312.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,597.42
|
| Rate for Payer: Anthem Medicare Advantage |
$8,639.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,639.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,639.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,639.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,094.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,639.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,382.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,639.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,639.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,639.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,639.99
|
| Rate for Payer: NAPHCARE Commercial |
$12,959.98
|
| Rate for Payer: Quartz Medicare Advantage |
$8,639.99
|
| Rate for Payer: The Alliance Commercial |
$24,019.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,639.99
|
| Rate for Payer: United Healthcare PPO |
$13,532.34
|
| Rate for Payer: Wellcare Medicare |
$8,639.99
|
|
|
DIGITAL BLOCK - SET-UP CHARGE
|
Facility
IP
|
$229.00
|
|
| Hospital Charge Code |
4519590
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$112.21 |
| Max. Negotiated Rate |
$210.68 |
| Rate for Payer: Aetna Commercial |
$206.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.37
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$210.68
|
| Rate for Payer: Health EOS Commercial |
$203.81
|
| Rate for Payer: HFN Commercial |
$210.68
|
| Rate for Payer: Multiplan Commercial |
$183.20
|
| Rate for Payer: NAPHCARE Commercial |
$137.40
|
| Rate for Payer: Preferred Network Access Commercial |
$210.68
|
| Rate for Payer: Quartz Beloit One Network |
$112.21
|
| Rate for Payer: Quartz Commercial |
$137.40
|
| Rate for Payer: WEA Trust Commercial |
$125.95
|
| Rate for Payer: WPS Commercial |
$169.62
|
|
|
DIGITAL BLOCK - SET-UP CHARGE
|
Facility
OP
|
$229.00
|
|
| Hospital Charge Code |
4519590
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.12 |
| Max. Negotiated Rate |
$916.00 |
| Rate for Payer: Aetna Commercial |
$206.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.94
|
| Rate for Payer: Aetna Managed Medicare |
$64.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.37
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$210.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.15
|
| Rate for Payer: Health EOS Commercial |
$203.81
|
| Rate for Payer: HFN Commercial |
$210.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.75
|
| Rate for Payer: Multiplan Commercial |
$183.20
|
| Rate for Payer: NAPHCARE Commercial |
$137.40
|
| Rate for Payer: Preferred Network Access Commercial |
$210.68
|
| Rate for Payer: Quartz Beloit One Network |
$112.21
|
| Rate for Payer: Quartz Commercial |
$148.85
|
| Rate for Payer: Quartz Medicare Advantage |
$137.40
|
| Rate for Payer: The Alliance Commercial |
$916.00
|
| Rate for Payer: WEA Trust Commercial |
$125.95
|
| Rate for Payer: WPS Commercial |
$169.62
|
|
|
DIGITAL CAP RIBBED KNIT S/M 10205
|
Facility
OP
|
$110.00
|
|
| Hospital Charge Code |
2971266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Aetna Managed Medicare |
$30.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.56
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.50
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$71.50
|
| Rate for Payer: Quartz Medicare Advantage |
$66.00
|
| Rate for Payer: The Alliance Commercial |
$440.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
DIGITAL CAP RIBBED KNIT S/M 10205
|
Facility
IP
|
$110.00
|
|
| Hospital Charge Code |
2971266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
