|
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 |
$49.28 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.35
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$145.86
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
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 |
$343.98 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$421.20
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
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 |
$196.56 |
| Max. Negotiated Rate |
$645.84 |
| Rate for Payer: Aetna Commercial |
$631.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Aetna Managed Medicare |
$196.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$456.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$351.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$336.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.06
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$392.85
|
| Rate for Payer: Health EOS Commercial |
$624.78
|
| Rate for Payer: HFN Commercial |
$645.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.50
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: NAPHCARE Commercial |
$421.20
|
| Rate for Payer: Preferred Network Access Commercial |
$645.84
|
| Rate for Payer: Quartz Beloit One Network |
$343.98
|
| Rate for Payer: Quartz Commercial |
$456.30
|
| Rate for Payer: Quartz Medicare Advantage |
$421.20
|
| Rate for Payer: The Alliance Commercial |
$252.22
|
| Rate for Payer: United Healthcare PPO |
$526.50
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.95
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$7,014.65
|
|
|
Service Code
|
APR-DRG 2401
|
| Min. Negotiated Rate |
$6,230.85 |
| Max. Negotiated Rate |
$7,014.65 |
| Rate for Payer: Anthem Medicaid |
$6,716.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,716.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,716.91
|
| Rate for Payer: Dean Health Medicaid |
$6,716.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,230.85
|
| Rate for Payer: Managed Health Services Medicaid |
$7,014.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,716.91
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,716.91
|
| Rate for Payer: United Healthcare Medicaid |
$6,716.91
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$12,714.05
|
|
|
Service Code
|
APR-DRG 2403
|
| Min. Negotiated Rate |
$11,293.41 |
| Max. Negotiated Rate |
$12,714.05 |
| Rate for Payer: Anthem Medicaid |
$12,174.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,174.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,174.40
|
| Rate for Payer: Dean Health Medicaid |
$12,174.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11,293.41
|
| Rate for Payer: Managed Health Services Medicaid |
$12,714.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,174.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,174.40
|
| Rate for Payer: United Healthcare Medicaid |
$12,174.40
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$20,254.80
|
|
|
Service Code
|
APR-DRG 2404
|
| Min. Negotiated Rate |
$17,991.57 |
| Max. Negotiated Rate |
$20,254.80 |
| Rate for Payer: Anthem Medicaid |
$19,395.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,395.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,395.08
|
| Rate for Payer: Dean Health Medicaid |
$19,395.08
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,991.57
|
| Rate for Payer: Managed Health Services Medicaid |
$20,254.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,395.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,395.08
|
| Rate for Payer: United Healthcare Medicaid |
$19,395.08
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$8,680.63
|
|
|
Service Code
|
APR-DRG 2402
|
| Min. Negotiated Rate |
$7,710.67 |
| Max. Negotiated Rate |
$8,680.63 |
| Rate for Payer: Anthem Medicaid |
$8,312.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,312.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,312.18
|
| Rate for Payer: Dean Health Medicaid |
$8,312.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,710.67
|
| Rate for Payer: Managed Health Services Medicaid |
$8,680.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,312.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,312.18
|
| Rate for Payer: United Healthcare Medicaid |
$8,312.18
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
OP
|
$82.55
|
|
|
Service Code
|
EAPG 00620
|
| Min. Negotiated Rate |
$79.37 |
| Max. Negotiated Rate |
$82.55 |
| Rate for Payer: Anthem Medicaid |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$79.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.37
|
| Rate for Payer: Dean Health Medicaid |
$79.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$79.37
|
| Rate for Payer: Managed Health Services Medicaid |
$82.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$79.37
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$79.37
|
| Rate for Payer: United Healthcare Medicaid |
$79.37
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$33,465.12
|
|
|
Service Code
|
MSDRG 375
|
| Min. Negotiated Rate |
$9,770.14 |
| Max. Negotiated Rate |
$33,465.12 |
| Rate for Payer: Aetna Managed Medicare |
$9,770.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,392.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,229.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,219.48
|
| Rate for Payer: Anthem Medicare Advantage |
$9,770.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,770.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,770.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,770.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,335.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,770.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,301.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,770.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,770.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,770.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,770.14
|
| Rate for Payer: NAPHCARE Commercial |
$14,655.22
|
| Rate for Payer: Quartz Medicare Advantage |
$9,770.14
|
| Rate for Payer: The Alliance Commercial |
$33,465.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,770.14
|
| Rate for Payer: United Healthcare PPO |
$18,919.05
|
| Rate for Payer: Wellcare Medicare |
$9,770.14
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$58,368.96
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$16,885.37 |
| Max. Negotiated Rate |
$58,368.96 |
| Rate for Payer: Aetna Managed Medicare |
$16,885.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,664.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,768.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,982.06
|
| Rate for Payer: Anthem Medicare Advantage |
$16,885.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,885.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,885.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,885.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,723.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,885.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42,567.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,885.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,885.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,885.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,885.37
|
| Rate for Payer: NAPHCARE Commercial |
$25,328.05
|
| Rate for Payer: Quartz Medicare Advantage |
$16,885.37
|
| Rate for Payer: The Alliance Commercial |
$58,368.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,885.37
|
| Rate for Payer: United Healthcare PPO |
$33,139.52
|
| Rate for Payer: Wellcare Medicare |
$16,885.37
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$24,979.76
|
|
|
Service Code
|
MSDRG 376
|
| Min. Negotiated Rate |
$7,585.25 |
| Max. Negotiated Rate |
$24,979.76 |
| Rate for Payer: Aetna Managed Medicare |
$7,585.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20,167.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,458.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,686.31
|
| Rate for Payer: Anthem Medicare Advantage |
$7,585.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,585.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,585.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,585.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16,303.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,585.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,077.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,585.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,585.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,585.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,585.25
|
| Rate for Payer: NAPHCARE Commercial |
$11,377.88
|
| Rate for Payer: Quartz Medicare Advantage |
$7,585.25
|
| Rate for Payer: The Alliance Commercial |
$24,979.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,585.25
|
| Rate for Payer: United Healthcare PPO |
$14,073.63
|
| Rate for Payer: Wellcare Medicare |
$7,585.25
|
|
|
DIGITAL BLOCK - SET-UP CHARGE
|
Facility
|
OP
|
$229.00
|
|
| Hospital Charge Code |
4519590
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.68 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Aetna Managed Medicare |
$66.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.28
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.62
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: NAPHCARE Commercial |
$142.90
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: Quartz Medicare Advantage |
$142.90
|
| Rate for Payer: The Alliance Commercial |
$119.08
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
DIGITAL BLOCK - SET-UP CHARGE
|
Facility
|
IP
|
$229.00
|
|
| Hospital Charge Code |
4519590
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$142.90
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
DIGITAL CAP RIBBED KNIT L/XL 10206
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2971213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
DIGITAL CAP RIBBED KNIT L/XL 10206
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2971213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
DIGITAL CAP RIBBED KNIT S/M 10205
|
Facility
|
OP
|
$110.00
|
|
| Hospital Charge Code |
2971266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.03 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$32.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.02
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.80
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$68.64
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$74.36
|
| Rate for Payer: Quartz Medicare Advantage |
$68.64
|
| Rate for Payer: The Alliance Commercial |
$57.20
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
DIGITAL CAP RIBBED KNIT S/M 10205
|
Facility
|
IP
|
$110.00
|
|
| Hospital Charge Code |
2971266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
DIGITAL MESH CAPS
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2971103
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
DIGITAL MESH CAPS
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2971103
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
DIGITAL PAD LG/XLG 10075
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
2969831
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
DIGITAL PAD LG/XLG 10075
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
2969831
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
DIGIT FINGER TRAPS 9906
|
Facility
|
OP
|
$317.00
|
|
| Hospital Charge Code |
2964911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$164.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.49
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.26
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$197.81
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$214.29
|
| Rate for Payer: Quartz Medicare Advantage |
$197.81
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
DIGIT FINGER TRAPS 9906
|
Facility
|
IP
|
$317.00
|
|
| Hospital Charge Code |
2964911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.54 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$197.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
Digoxin Level
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
633719
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.15 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$139.78
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
Digoxin Level
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
633719
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Aetna Managed Medicare |
$13.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.93
|
| Rate for Payer: Anthem Medicare Advantage |
$13.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.81
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.81
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.81
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.81
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: NAPHCARE Commercial |
$20.72
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$151.42
|
| Rate for Payer: Quartz Medicare Advantage |
$13.81
|
| Rate for Payer: The Alliance Commercial |
$55.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.81
|
| Rate for Payer: United Healthcare PPO |
$174.72
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: Wellcare Medicare |
$13.81
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
