|
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
|
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 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 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 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 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
|
|
|
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
|
|
|
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
|
|
|
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
|
|
|
Digoxin Level
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
633719
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$221.31 |
| Rate for Payer: Aetna Commercial |
$221.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Aetna Managed Medicare |
$13.81
|
| Rate for Payer: Anthem Medicare Advantage |
$13.81
|
| 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 |
$221.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$116.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.81
|
| Rate for Payer: Health EOS Commercial |
$211.99
|
| Rate for Payer: HFN Commercial |
$221.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.81
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: NAPHCARE Commercial |
$20.72
|
| Rate for Payer: Preferred Network Access Commercial |
$221.31
|
| Rate for Payer: Quartz Beloit One Network |
$102.50
|
| Rate for Payer: Quartz Commercial |
$132.79
|
| Rate for Payer: Quartz Medicare Advantage |
$13.81
|
| Rate for Payer: The Alliance Commercial |
$54.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.81
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$60.77
|
|
|
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
|
|
|
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
|
|
|
Dihydrorhodamine Flow Cytometric Test
|
Professional
|
Both
|
$938.00
|
|
|
Service Code
|
CPT 86352
|
| Hospital Charge Code |
6175444
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.29 |
| Max. Negotiated Rate |
$926.74 |
| Rate for Payer: Aetna Commercial |
$926.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$838.95
|
| Rate for Payer: Aetna Managed Medicare |
$141.29
|
| Rate for Payer: Anthem Medicare Advantage |
$141.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.29
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cigna Commercial |
$926.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$487.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.29
|
| Rate for Payer: Health EOS Commercial |
$887.72
|
| Rate for Payer: HFN Commercial |
$926.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$498.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.29
|
| Rate for Payer: Multiplan Commercial |
$780.42
|
| Rate for Payer: NAPHCARE Commercial |
$211.94
|
| Rate for Payer: Preferred Network Access Commercial |
$926.74
|
| Rate for Payer: Quartz Beloit One Network |
$429.23
|
| Rate for Payer: Quartz Commercial |
$556.05
|
| Rate for Payer: Quartz Medicare Advantage |
$141.29
|
| Rate for Payer: The Alliance Commercial |
$558.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.29
|
| Rate for Payer: WEA Trust Commercial |
$536.54
|
| Rate for Payer: WPS Commercial |
$621.70
|
|
|
Dihydrorhodamine Flow Cytometric Test
|
Facility
|
IP
|
$938.00
|
|
|
Service Code
|
CPT 86352
|
| Hospital Charge Code |
6175444
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$478.00 |
| Max. Negotiated Rate |
$897.48 |
| Rate for Payer: Aetna Commercial |
$877.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$838.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$517.03
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cigna Commercial |
$897.48
|
| Rate for Payer: Health EOS Commercial |
$868.21
|
| Rate for Payer: HFN Commercial |
$897.48
|
| Rate for Payer: Multiplan Commercial |
$780.42
|
| Rate for Payer: Preferred Network Access Commercial |
$897.48
|
| Rate for Payer: Quartz Beloit One Network |
$478.00
|
| Rate for Payer: Quartz Commercial |
$585.31
|
| Rate for Payer: WEA Trust Commercial |
$536.54
|
| Rate for Payer: WPS Commercial |
$722.54
|
|
|
Dihydrorhodamine Flow Cytometric Test
|
Facility
|
OP
|
$938.00
|
|
|
Service Code
|
CPT 86352
|
| Hospital Charge Code |
6175444
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.29 |
| Max. Negotiated Rate |
$897.48 |
| Rate for Payer: Aetna Commercial |
$877.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$838.95
|
| Rate for Payer: Aetna Managed Medicare |
$141.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$529.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$247.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.55
|
| Rate for Payer: Anthem Medicare Advantage |
$141.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$517.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.29
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Cigna Commercial |
$897.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$141.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$545.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$141.29
|
| Rate for Payer: Health EOS Commercial |
$868.21
|
| Rate for Payer: HFN Commercial |
$897.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$141.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$141.29
|
| Rate for Payer: Multiplan Commercial |
$780.42
|
| Rate for Payer: NAPHCARE Commercial |
$211.94
|
| Rate for Payer: Preferred Network Access Commercial |
$897.48
|
| Rate for Payer: Quartz Beloit One Network |
$478.00
|
| Rate for Payer: Quartz Commercial |
$634.09
|
| Rate for Payer: Quartz Medicare Advantage |
$141.29
|
| Rate for Payer: The Alliance Commercial |
$565.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.29
|
| Rate for Payer: United Healthcare PPO |
$731.64
|
| Rate for Payer: WEA Trust Commercial |
$536.54
|
| Rate for Payer: Wellcare Medicare |
$141.29
|
| Rate for Payer: WPS Commercial |
$722.54
|
|
|
Dihydrotestosterone, LC/MS/MS
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
CPT 80327
|
| Hospital Charge Code |
3400168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$210.44 |
| Rate for Payer: Aetna Commercial |
$210.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$210.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.91
|
| Rate for Payer: Health EOS Commercial |
$201.58
|
| Rate for Payer: HFN Commercial |
$210.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$210.44
|
| Rate for Payer: Quartz Beloit One Network |
$97.47
|
| Rate for Payer: Quartz Commercial |
$126.27
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
Dihydrotestosterone, LC/MS/MS
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
CPT 80327
|
| Hospital Charge Code |
3400168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.03 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$62.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.14
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$132.91
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$132.91
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: United Healthcare PPO |
$166.14
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
Dihydrotestosterone, LC/MS/MS
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
CPT 80327
|
| Hospital Charge Code |
3400168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
Dilate Tear Duct Opening 6880150
|
Professional
|
Both
|
$525.00
|
|
|
Service Code
|
CPT 68801 50
|
| Hospital Charge Code |
3798683
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$518.70 |
| Rate for Payer: Aetna Commercial |
$518.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$469.56
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$518.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.60
|
| Rate for Payer: Health EOS Commercial |
$496.86
|
| Rate for Payer: HFN Commercial |
$518.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$274.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$274.67
|
| Rate for Payer: Multiplan Commercial |
$436.80
|
| Rate for Payer: Preferred Network Access Commercial |
$518.70
|
| Rate for Payer: Quartz Beloit One Network |
$240.24
|
| Rate for Payer: Quartz Commercial |
$311.22
|
| Rate for Payer: The Alliance Commercial |
$273.00
|
| Rate for Payer: United Healthcare Medicaid |
$45.50
|
| Rate for Payer: WEA Trust Commercial |
$300.30
|
| Rate for Payer: WPS Commercial |
$404.41
|
|
|
DILATION AND CURETTAGE 58120
|
Professional
|
Both
|
$1,648.00
|
|
|
Service Code
|
CPT 58120
|
| Hospital Charge Code |
3015096
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$199.42 |
| Max. Negotiated Rate |
$1,628.22 |
| Rate for Payer: Aetna Commercial |
$1,628.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,473.97
|
| Rate for Payer: Aetna Managed Medicare |
$199.42
|
| Rate for Payer: Anthem Medicare Advantage |
$199.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$199.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$199.42
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Cigna Commercial |
$1,628.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.42
|
| Rate for Payer: Health EOS Commercial |
$1,559.67
|
| Rate for Payer: HFN Commercial |
$1,628.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$801.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$801.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$199.42
|
| Rate for Payer: Multiplan Commercial |
$1,371.14
|
| Rate for Payer: NAPHCARE Commercial |
$299.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,628.22
|
| Rate for Payer: Quartz Beloit One Network |
$754.12
|
| Rate for Payer: Quartz Commercial |
$976.93
|
| Rate for Payer: Quartz Medicare Advantage |
$199.42
|
| Rate for Payer: The Alliance Commercial |
$847.53
|
| Rate for Payer: United Healthcare Medicaid |
$239.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$199.42
|
| Rate for Payer: WEA Trust Commercial |
$942.66
|
| Rate for Payer: WPS Commercial |
$897.39
|
|
|
DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)
|
Facility
|
OP
|
$13,626.87
|
|
|
Service Code
|
CPT 58120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$13,626.87 |
| Rate for Payer: Aetna Managed Medicare |
$3,406.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,406.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,406.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,406.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,406.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,672.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,406.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,406.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,406.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,406.72
|
| Rate for Payer: NAPHCARE Commercial |
$5,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,406.72
|
| Rate for Payer: The Alliance Commercial |
$13,626.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,406.72
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$3,406.72
|
|
|
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
|
Facility
|
IP
|
$14,818.44
|
|
|
Service Code
|
APR-DRG 5173
|
| Min. Negotiated Rate |
$13,162.67 |
| Max. Negotiated Rate |
$14,818.44 |
| Rate for Payer: Anthem Medicaid |
$14,189.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,189.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,189.48
|
| Rate for Payer: Dean Health Medicaid |
$14,189.48
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,162.67
|
| Rate for Payer: Managed Health Services Medicaid |
$14,818.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,189.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,189.48
|
| Rate for Payer: United Healthcare Medicaid |
$14,189.48
|
|
