|
Direct Admit Hospital Observ
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
3791433
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.45 |
| Max. Negotiated Rate |
$2,506.94 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Aetna Managed Medicare |
$626.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.45
|
| Rate for Payer: Anthem Medicare Advantage |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$626.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$626.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$626.74
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$626.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$626.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$626.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$626.74
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: NAPHCARE Commercial |
$940.10
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$39.88
|
| Rate for Payer: Quartz Medicare Advantage |
$626.74
|
| Rate for Payer: The Alliance Commercial |
$2,506.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$626.74
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: Wellcare Medicare |
$626.74
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
|
Direct Antiglobulin Test
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$235.79 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.61
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.61
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$8.41
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5.61
|
| Rate for Payer: The Alliance Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.61
|
| Rate for Payer: United Healthcare PPO |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: Wellcare Medicare |
$5.61
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Direct Antiglobulin Test
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Direct Antiglobulin Test Cord
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$235.79 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.61
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.61
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$8.41
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5.61
|
| Rate for Payer: The Alliance Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.61
|
| Rate for Payer: United Healthcare PPO |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: Wellcare Medicare |
$5.61
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Direct Antiglobulin Test Cord
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Direct Antiglobulin Test Heel
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$235.79 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.61
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.61
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.61
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$8.41
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$5.61
|
| Rate for Payer: The Alliance Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.61
|
| Rate for Payer: United Healthcare PPO |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: Wellcare Medicare |
$5.61
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Direct Antiglobulin Test Heel
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
985764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY
|
Facility
|
OP
|
$23,424.04
|
|
|
Service Code
|
CPT 35045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$23,424.04 |
| Rate for Payer: Aetna Managed Medicare |
$5,856.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,856.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,856.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,856.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,856.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,856.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,784.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,856.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,856.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,856.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,856.01
|
| Rate for Payer: NAPHCARE Commercial |
$8,784.02
|
| Rate for Payer: Quartz Medicare Advantage |
$5,856.01
|
| Rate for Payer: The Alliance Commercial |
$23,424.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,856.01
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$5,856.01
|
|
|
DISCECTOMY, MICRO
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2960231
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,203.51 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,698.18
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
DISCECTOMY, MICRO
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2960231
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,259.15 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,248.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,158.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,516.57
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,372.72
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,923.02
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.18
|
| Rate for Payer: The Alliance Commercial |
$2,248.48
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
discontinuedCDS MINOR PROCEDURE DYNJ900884
|
Facility
|
OP
|
$1,115.00
|
|
| Hospital Charge Code |
4124769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$324.69 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Aetna Managed Medicare |
$324.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$753.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$579.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$648.93
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$869.70
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: NAPHCARE Commercial |
$695.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$753.74
|
| Rate for Payer: Quartz Medicare Advantage |
$695.76
|
| Rate for Payer: The Alliance Commercial |
$579.80
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
discontinuedCDS MINOR PROCEDURE DYNJ900884
|
Facility
|
IP
|
$1,115.00
|
|
| Hospital Charge Code |
4124769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$568.20 |
| Max. Negotiated Rate |
$1,066.83 |
| Rate for Payer: Aetna Commercial |
$1,043.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.59
|
| Rate for Payer: Cash Price |
$334.50
|
| Rate for Payer: Cigna Commercial |
$1,066.83
|
| Rate for Payer: Health EOS Commercial |
$1,032.04
|
| Rate for Payer: HFN Commercial |
$1,066.83
|
| Rate for Payer: Multiplan Commercial |
$927.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.83
|
| Rate for Payer: Quartz Beloit One Network |
$568.20
|
| Rate for Payer: Quartz Commercial |
$695.76
|
| Rate for Payer: WEA Trust Commercial |
$637.78
|
| Rate for Payer: WPS Commercial |
$858.88
|
|
|
discontinuedCUFF B/P CHILD REUSABLE
|
Facility
|
IP
|
$186.00
|
|
| Hospital Charge Code |
2963397
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
discontinuedCUFF B/P CHILD REUSABLE
|
Facility
|
OP
|
$186.00
|
|
| Hospital Charge Code |
2963397
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.25
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Discontinued - IABP Activity
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
CPT 33968
|
| Hospital Charge Code |
3034567
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$673.18 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$824.30
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
Discontinued - IABP Activity
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
CPT 33968
|
| Hospital Charge Code |
3034567
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Aetna Managed Medicare |
$384.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,030.38
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: NAPHCARE Commercial |
$824.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$893.00
|
| Rate for Payer: Quartz Medicare Advantage |
$824.30
|
| Rate for Payer: The Alliance Commercial |
$109.45
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
DISCONTINUED STAPLER ENDOCUTTER 35MM (BLUE) ATB35
|
Facility
|
OP
|
$2,456.00
|
|
| Hospital Charge Code |
3591517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$715.19 |
| Max. Negotiated Rate |
$2,349.90 |
| Rate for Payer: Aetna Commercial |
$2,298.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,196.65
|
| Rate for Payer: Aetna Managed Medicare |
$715.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,660.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,277.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,226.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,353.75
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$2,349.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,429.39
|
| Rate for Payer: Health EOS Commercial |
$2,273.27
|
| Rate for Payer: HFN Commercial |
$2,349.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,915.68
|
| Rate for Payer: Multiplan Commercial |
$2,043.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,532.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,349.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.58
|
| Rate for Payer: Quartz Commercial |
$1,660.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,532.54
|
| Rate for Payer: The Alliance Commercial |
$1,277.12
|
| Rate for Payer: WEA Trust Commercial |
$1,404.83
|
| Rate for Payer: WPS Commercial |
$1,891.86
|
|
|
DISCONTINUED STAPLER ENDOCUTTER 35MM (BLUE) ATB35
|
Facility
|
IP
|
$2,456.00
|
|
| Hospital Charge Code |
3591517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,251.58 |
| Max. Negotiated Rate |
$2,349.90 |
| Rate for Payer: Aetna Commercial |
$2,298.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,196.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,353.75
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$2,349.90
|
| Rate for Payer: Health EOS Commercial |
$2,273.27
|
| Rate for Payer: HFN Commercial |
$2,349.90
|
| Rate for Payer: Multiplan Commercial |
$2,043.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,349.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.58
|
| Rate for Payer: Quartz Commercial |
$1,532.54
|
| Rate for Payer: WEA Trust Commercial |
$1,404.83
|
| Rate for Payer: WPS Commercial |
$1,891.86
|
|
|
DISCONTINUED STAPLER ENDOCUTTER 35MM (WHITE) ATW35
|
Facility
|
IP
|
$2,456.00
|
|
| Hospital Charge Code |
3789658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,251.58 |
| Max. Negotiated Rate |
$2,349.90 |
| Rate for Payer: Aetna Commercial |
$2,298.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,196.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,353.75
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$2,349.90
|
| Rate for Payer: Health EOS Commercial |
$2,273.27
|
| Rate for Payer: HFN Commercial |
$2,349.90
|
| Rate for Payer: Multiplan Commercial |
$2,043.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,349.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.58
|
| Rate for Payer: Quartz Commercial |
$1,532.54
|
| Rate for Payer: WEA Trust Commercial |
$1,404.83
|
| Rate for Payer: WPS Commercial |
$1,891.86
|
|
|
DISCONTINUED STAPLER ENDOCUTTER 35MM (WHITE) ATW35
|
Facility
|
OP
|
$2,456.00
|
|
| Hospital Charge Code |
3789658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$715.19 |
| Max. Negotiated Rate |
$2,349.90 |
| Rate for Payer: Aetna Commercial |
$2,298.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,196.65
|
| Rate for Payer: Aetna Managed Medicare |
$715.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,660.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,277.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,226.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,353.75
|
| Rate for Payer: Cash Price |
$736.80
|
| Rate for Payer: Cigna Commercial |
$2,349.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,429.39
|
| Rate for Payer: Health EOS Commercial |
$2,273.27
|
| Rate for Payer: HFN Commercial |
$2,349.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,915.68
|
| Rate for Payer: Multiplan Commercial |
$2,043.39
|
| Rate for Payer: NAPHCARE Commercial |
$1,532.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,349.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.58
|
| Rate for Payer: Quartz Commercial |
$1,660.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,532.54
|
| Rate for Payer: The Alliance Commercial |
$1,277.12
|
| Rate for Payer: WEA Trust Commercial |
$1,404.83
|
| Rate for Payer: WPS Commercial |
$1,891.86
|
|
|
DISCONTINUED STAPLER RELOAD ENDOCUTTER 35MM (BLUE) TR35B
|
Facility
|
IP
|
$1,588.00
|
|
| Hospital Charge Code |
3591516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$809.24 |
| Max. Negotiated Rate |
$1,519.40 |
| Rate for Payer: Aetna Commercial |
$1,486.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,420.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$875.31
|
| Rate for Payer: Cash Price |
$476.40
|
| Rate for Payer: Cigna Commercial |
$1,519.40
|
| Rate for Payer: Health EOS Commercial |
$1,469.85
|
| Rate for Payer: HFN Commercial |
$1,519.40
|
| Rate for Payer: Multiplan Commercial |
$1,321.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,519.40
|
| Rate for Payer: Quartz Beloit One Network |
$809.24
|
| Rate for Payer: Quartz Commercial |
$990.91
|
| Rate for Payer: WEA Trust Commercial |
$908.34
|
| Rate for Payer: WPS Commercial |
$1,223.24
|
|
|
DISCONTINUED STAPLER RELOAD ENDOCUTTER 35MM (BLUE) TR35B
|
Facility
|
OP
|
$1,588.00
|
|
| Hospital Charge Code |
3591516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.43 |
| Max. Negotiated Rate |
$1,519.40 |
| Rate for Payer: Aetna Commercial |
$1,486.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,420.31
|
| Rate for Payer: Aetna Managed Medicare |
$462.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,073.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$825.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$792.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$875.31
|
| Rate for Payer: Cash Price |
$476.40
|
| Rate for Payer: Cigna Commercial |
$1,519.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$924.22
|
| Rate for Payer: Health EOS Commercial |
$1,469.85
|
| Rate for Payer: HFN Commercial |
$1,519.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,238.64
|
| Rate for Payer: Multiplan Commercial |
$1,321.22
|
| Rate for Payer: NAPHCARE Commercial |
$990.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,519.40
|
| Rate for Payer: Quartz Beloit One Network |
$809.24
|
| Rate for Payer: Quartz Commercial |
$1,073.49
|
| Rate for Payer: Quartz Medicare Advantage |
$990.91
|
| Rate for Payer: The Alliance Commercial |
$825.76
|
| Rate for Payer: WEA Trust Commercial |
$908.34
|
| Rate for Payer: WPS Commercial |
$1,223.24
|
|
|
DISCOVISC LATEX FREE
|
Facility
|
OP
|
$1,774.00
|
|
| Hospital Charge Code |
2974042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.59 |
| Max. Negotiated Rate |
$1,697.36 |
| Rate for Payer: Aetna Commercial |
$1,660.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,586.67
|
| Rate for Payer: Aetna Managed Medicare |
$516.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$922.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$885.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.83
|
| Rate for Payer: Cash Price |
$532.20
|
| Rate for Payer: Cigna Commercial |
$1,697.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,032.47
|
| Rate for Payer: Health EOS Commercial |
$1,642.01
|
| Rate for Payer: HFN Commercial |
$1,697.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,383.72
|
| Rate for Payer: Multiplan Commercial |
$1,475.97
|
| Rate for Payer: NAPHCARE Commercial |
$1,106.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,697.36
|
| Rate for Payer: Quartz Beloit One Network |
$904.03
|
| Rate for Payer: Quartz Commercial |
$1,199.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,106.98
|
| Rate for Payer: The Alliance Commercial |
$922.48
|
| Rate for Payer: WEA Trust Commercial |
$1,014.73
|
| Rate for Payer: WPS Commercial |
$1,366.51
|
|
|
DISCOVISC LATEX FREE
|
Facility
|
IP
|
$1,774.00
|
|
| Hospital Charge Code |
2974042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.03 |
| Max. Negotiated Rate |
$1,697.36 |
| Rate for Payer: Aetna Commercial |
$1,660.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,586.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.83
|
| Rate for Payer: Cash Price |
$532.20
|
| Rate for Payer: Cigna Commercial |
$1,697.36
|
| Rate for Payer: Health EOS Commercial |
$1,642.01
|
| Rate for Payer: HFN Commercial |
$1,697.36
|
| Rate for Payer: Multiplan Commercial |
$1,475.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,697.36
|
| Rate for Payer: Quartz Beloit One Network |
$904.03
|
| Rate for Payer: Quartz Commercial |
$1,106.98
|
| Rate for Payer: WEA Trust Commercial |
$1,014.73
|
| Rate for Payer: WPS Commercial |
$1,366.51
|
|
|
DISCOVISC LATEX FREE 8065183710
|
Facility
|
IP
|
$1,774.00
|
|
| Hospital Charge Code |
2972456
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.03 |
| Max. Negotiated Rate |
$1,697.36 |
| Rate for Payer: Aetna Commercial |
$1,660.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,586.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$977.83
|
| Rate for Payer: Cash Price |
$532.20
|
| Rate for Payer: Cigna Commercial |
$1,697.36
|
| Rate for Payer: Health EOS Commercial |
$1,642.01
|
| Rate for Payer: HFN Commercial |
$1,697.36
|
| Rate for Payer: Multiplan Commercial |
$1,475.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,697.36
|
| Rate for Payer: Quartz Beloit One Network |
$904.03
|
| Rate for Payer: Quartz Commercial |
$1,106.98
|
| Rate for Payer: WEA Trust Commercial |
$1,014.73
|
| Rate for Payer: WPS Commercial |
$1,366.51
|
|
