|
***DO NOT USE***GRAFT INTERGARD 14X7MM BIF IGK1407***DO NOT USE ON PREF CARD***
|
Facility
|
OP
|
$6,505.00
|
|
| Hospital Charge Code |
2965277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,894.26 |
| Max. Negotiated Rate |
$6,223.98 |
| Rate for Payer: Aetna Commercial |
$6,088.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,818.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,894.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,397.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,382.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,247.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,585.56
|
| Rate for Payer: Cash Price |
$1,951.50
|
| Rate for Payer: Cigna Commercial |
$6,223.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,785.91
|
| Rate for Payer: Health EOS Commercial |
$6,021.03
|
| Rate for Payer: HFN Commercial |
$6,223.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,073.90
|
| Rate for Payer: Multiplan Commercial |
$5,412.16
|
| Rate for Payer: NAPHCARE Commercial |
$4,059.12
|
| Rate for Payer: Preferred Network Access Commercial |
$6,223.98
|
| Rate for Payer: Quartz Beloit One Network |
$3,314.95
|
| Rate for Payer: Quartz Commercial |
$4,397.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4,059.12
|
| Rate for Payer: The Alliance Commercial |
$3,382.60
|
| Rate for Payer: WEA Trust Commercial |
$3,720.86
|
| Rate for Payer: WPS Commercial |
$5,010.80
|
|
|
***DO NOT USE ON PREF CARD***ABSORBATACK 5MM HERNIA TACKER ABSTACK30***DO NOT USE ON PREF CARD***
|
Facility
|
OP
|
$1,917.00
|
|
| Hospital Charge Code |
2962848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$558.23 |
| Max. Negotiated Rate |
$1,834.19 |
| Rate for Payer: Aetna Commercial |
$1,794.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,714.56
|
| Rate for Payer: Aetna Managed Medicare |
$558.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,295.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$996.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$956.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,056.65
|
| Rate for Payer: Cash Price |
$575.10
|
| Rate for Payer: Cigna Commercial |
$1,834.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,115.69
|
| Rate for Payer: Health EOS Commercial |
$1,774.38
|
| Rate for Payer: HFN Commercial |
$1,834.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,495.26
|
| Rate for Payer: Multiplan Commercial |
$1,594.94
|
| Rate for Payer: NAPHCARE Commercial |
$1,196.21
|
| Rate for Payer: Preferred Network Access Commercial |
$1,834.19
|
| Rate for Payer: Quartz Beloit One Network |
$976.90
|
| Rate for Payer: Quartz Commercial |
$1,295.89
|
| Rate for Payer: Quartz Medicare Advantage |
$1,196.21
|
| Rate for Payer: The Alliance Commercial |
$996.84
|
| Rate for Payer: WEA Trust Commercial |
$1,096.52
|
| Rate for Payer: WPS Commercial |
$1,476.67
|
|
|
***DO NOT USE ON PREF CARD***ABSORBATACK 5MM HERNIA TACKER ABSTACK30***DO NOT USE ON PREF CARD***
|
Facility
|
IP
|
$1,917.00
|
|
| Hospital Charge Code |
2962848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$976.90 |
| Max. Negotiated Rate |
$1,834.19 |
| Rate for Payer: Aetna Commercial |
$1,794.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,714.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,056.65
|
| Rate for Payer: Cash Price |
$575.10
|
| Rate for Payer: Cigna Commercial |
$1,834.19
|
| Rate for Payer: Health EOS Commercial |
$1,774.38
|
| Rate for Payer: HFN Commercial |
$1,834.19
|
| Rate for Payer: Multiplan Commercial |
$1,594.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,834.19
|
| Rate for Payer: Quartz Beloit One Network |
$976.90
|
| Rate for Payer: Quartz Commercial |
$1,196.21
|
| Rate for Payer: WEA Trust Commercial |
$1,096.52
|
| Rate for Payer: WPS Commercial |
$1,476.67
|
|
|
Dopamine, Plasma
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$100.21 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$23.40
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Dopamine, Plasma
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$110.24 |
| Rate for Payer: Aetna Commercial |
$29.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$29.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$28.39
|
| Rate for Payer: HFN Commercial |
$29.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$29.64
|
| Rate for Payer: Quartz Beloit One Network |
$13.73
|
| Rate for Payer: Quartz Commercial |
$17.78
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
Dopamine, Plasma
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Dopamine, Urine
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$328.02 |
| Rate for Payer: Aetna Commercial |
$328.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$328.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$314.20
|
| Rate for Payer: HFN Commercial |
$328.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$328.02
|
| Rate for Payer: Quartz Beloit One Network |
$151.92
|
| Rate for Payer: Quartz Commercial |
$196.81
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
Dopamine, Urine
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$207.17
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
Dopamine, Urine
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
4522641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$224.43
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
DOP Echocard Pulse Wave W/Spectral 93321
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
CPT 93321
|
| Hospital Charge Code |
5104618
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$232.18 |
| Rate for Payer: Aetna Commercial |
$232.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Aetna Managed Medicare |
$25.28
|
| Rate for Payer: Anthem Medicare Advantage |
$25.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.28
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$232.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.28
|
| Rate for Payer: Health EOS Commercial |
$222.40
|
| Rate for Payer: HFN Commercial |
$232.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$94.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.28
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: NAPHCARE Commercial |
$37.92
|
| Rate for Payer: Preferred Network Access Commercial |
$232.18
|
| Rate for Payer: Quartz Beloit One Network |
$107.54
|
| Rate for Payer: Quartz Commercial |
$139.31
|
| Rate for Payer: Quartz Medicare Advantage |
$25.28
|
| Rate for Payer: The Alliance Commercial |
$96.07
|
| Rate for Payer: United Healthcare Medicaid |
$32.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.28
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: WPS Commercial |
$101.13
|
|
|
DOP Echocard Pulse Wave W/Spectral 9332126
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
CPT 93321 26
|
| Hospital Charge Code |
5104619
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$232.18 |
| Rate for Payer: Aetna Commercial |
$232.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Aetna Managed Medicare |
$7.31
|
| Rate for Payer: Anthem Medicare Advantage |
$7.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.31
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$232.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.31
|
| Rate for Payer: Health EOS Commercial |
$222.40
|
| Rate for Payer: HFN Commercial |
$232.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.31
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: NAPHCARE Commercial |
$10.97
|
| Rate for Payer: Preferred Network Access Commercial |
$232.18
|
| Rate for Payer: Quartz Beloit One Network |
$107.54
|
| Rate for Payer: Quartz Commercial |
$139.31
|
| Rate for Payer: Quartz Medicare Advantage |
$7.31
|
| Rate for Payer: The Alliance Commercial |
$27.78
|
| Rate for Payer: United Healthcare Medicaid |
$8.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.31
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: WPS Commercial |
$29.24
|
|
|
DOPPLER COLOR FLOW ADD-ON 9332526
|
Professional
|
Both
|
$126.00
|
|
|
Service Code
|
CPT 93325 26
|
| Hospital Charge Code |
3015379
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$124.49 |
| Rate for Payer: Aetna Commercial |
$124.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.69
|
| Rate for Payer: Aetna Managed Medicare |
$3.43
|
| Rate for Payer: Anthem Medicare Advantage |
$3.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.43
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$124.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.43
|
| Rate for Payer: Health EOS Commercial |
$119.25
|
| Rate for Payer: HFN Commercial |
$124.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$104.83
|
| Rate for Payer: NAPHCARE Commercial |
$5.15
|
| Rate for Payer: Preferred Network Access Commercial |
$124.49
|
| Rate for Payer: Quartz Beloit One Network |
$57.66
|
| Rate for Payer: Quartz Commercial |
$74.69
|
| Rate for Payer: Quartz Medicare Advantage |
$3.43
|
| Rate for Payer: The Alliance Commercial |
$13.04
|
| Rate for Payer: United Healthcare Medicaid |
$3.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.43
|
| Rate for Payer: WEA Trust Commercial |
$72.07
|
| Rate for Payer: WPS Commercial |
$13.73
|
|
|
DOPPLER ECHO EXAM, HEART 9332026
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
CPT 93320 26
|
| Hospital Charge Code |
3015377
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.62 |
| Max. Negotiated Rate |
$410.02 |
| Rate for Payer: Aetna Commercial |
$410.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.62
|
| Rate for Payer: Anthem Medicare Advantage |
$17.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.62
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$410.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.62
|
| Rate for Payer: Health EOS Commercial |
$392.76
|
| Rate for Payer: HFN Commercial |
$410.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.62
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: NAPHCARE Commercial |
$26.43
|
| Rate for Payer: Preferred Network Access Commercial |
$410.02
|
| Rate for Payer: Quartz Beloit One Network |
$189.90
|
| Rate for Payer: Quartz Commercial |
$246.01
|
| Rate for Payer: Quartz Medicare Advantage |
$17.62
|
| Rate for Payer: The Alliance Commercial |
$66.95
|
| Rate for Payer: United Healthcare Medicaid |
$20.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.62
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$70.47
|
|
|
DOPPLER FLOW TESTING 9399026
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
CPT 93990 26
|
| Hospital Charge Code |
3015450
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$85.74 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.43
|
| Rate for Payer: Anthem Medicare Advantage |
$21.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.43
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.43
|
| Rate for Payer: Health EOS Commercial |
$70.98
|
| Rate for Payer: HFN Commercial |
$74.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.43
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$32.15
|
| Rate for Payer: Preferred Network Access Commercial |
$74.10
|
| Rate for Payer: Quartz Beloit One Network |
$34.32
|
| Rate for Payer: Quartz Commercial |
$44.46
|
| Rate for Payer: Quartz Medicare Advantage |
$21.43
|
| Rate for Payer: The Alliance Commercial |
$53.59
|
| Rate for Payer: United Healthcare Medicaid |
$13.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.43
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$85.74
|
|
|
DOPPLER POCKET OB #FD3-P-USA
|
Facility
|
OP
|
$7,104.00
|
|
| Hospital Charge Code |
2969841
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,068.68 |
| Max. Negotiated Rate |
$6,797.11 |
| Rate for Payer: Aetna Commercial |
$6,649.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,353.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,068.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,802.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,694.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,915.72
|
| Rate for Payer: Cash Price |
$2,131.20
|
| Rate for Payer: Cigna Commercial |
$6,797.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,134.53
|
| Rate for Payer: Health EOS Commercial |
$6,575.46
|
| Rate for Payer: HFN Commercial |
$6,797.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,541.12
|
| Rate for Payer: Multiplan Commercial |
$5,910.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,432.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,797.11
|
| Rate for Payer: Quartz Beloit One Network |
$3,620.20
|
| Rate for Payer: Quartz Commercial |
$4,802.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,432.90
|
| Rate for Payer: The Alliance Commercial |
$3,694.08
|
| Rate for Payer: WEA Trust Commercial |
$4,063.49
|
| Rate for Payer: WPS Commercial |
$5,472.21
|
|
|
DOPPLER POCKET OB #FD3-P-USA
|
Facility
|
IP
|
$7,104.00
|
|
| Hospital Charge Code |
2969841
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3,620.20 |
| Max. Negotiated Rate |
$6,797.11 |
| Rate for Payer: Aetna Commercial |
$6,649.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,353.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,915.72
|
| Rate for Payer: Cash Price |
$2,131.20
|
| Rate for Payer: Cigna Commercial |
$6,797.11
|
| Rate for Payer: Health EOS Commercial |
$6,575.46
|
| Rate for Payer: HFN Commercial |
$6,797.11
|
| Rate for Payer: Multiplan Commercial |
$5,910.53
|
| Rate for Payer: Preferred Network Access Commercial |
$6,797.11
|
| Rate for Payer: Quartz Beloit One Network |
$3,620.20
|
| Rate for Payer: Quartz Commercial |
$4,432.90
|
| Rate for Payer: WEA Trust Commercial |
$4,063.49
|
| Rate for Payer: WPS Commercial |
$5,472.21
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$29,636.89
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$26,325.33 |
| Max. Negotiated Rate |
$29,636.89 |
| Rate for Payer: Anthem Medicaid |
$28,378.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28,378.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28,378.95
|
| Rate for Payer: Dean Health Medicaid |
$28,378.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26,325.33
|
| Rate for Payer: Managed Health Services Medicaid |
$29,636.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,378.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28,378.95
|
| Rate for Payer: United Healthcare Medicaid |
$28,378.95
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$56,029.50
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$49,768.90 |
| Max. Negotiated Rate |
$56,029.50 |
| Rate for Payer: Anthem Medicaid |
$53,651.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$53,651.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53,651.33
|
| Rate for Payer: Dean Health Medicaid |
$53,651.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$49,768.90
|
| Rate for Payer: Managed Health Services Medicaid |
$56,029.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$53,651.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$53,651.33
|
| Rate for Payer: United Healthcare Medicaid |
$53,651.33
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$41,298.74
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$36,684.12 |
| Max. Negotiated Rate |
$41,298.74 |
| Rate for Payer: Anthem Medicaid |
$39,545.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$39,545.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39,545.82
|
| Rate for Payer: Dean Health Medicaid |
$39,545.82
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36,684.12
|
| Rate for Payer: Managed Health Services Medicaid |
$41,298.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$39,545.82
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$39,545.82
|
| Rate for Payer: United Healthcare Medicaid |
$39,545.82
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$21,745.41
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$19,315.63 |
| Max. Negotiated Rate |
$21,745.41 |
| Rate for Payer: Anthem Medicaid |
$20,822.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20,822.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20,822.43
|
| Rate for Payer: Dean Health Medicaid |
$20,822.43
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19,315.63
|
| Rate for Payer: Managed Health Services Medicaid |
$21,745.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,822.43
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20,822.43
|
| Rate for Payer: United Healthcare Medicaid |
$20,822.43
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$34,722.51
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$30,842.70 |
| Max. Negotiated Rate |
$34,722.51 |
| Rate for Payer: Anthem Medicaid |
$33,248.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$33,248.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33,248.71
|
| Rate for Payer: Dean Health Medicaid |
$33,248.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30,842.70
|
| Rate for Payer: Managed Health Services Medicaid |
$34,722.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,248.71
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$33,248.71
|
| Rate for Payer: United Healthcare Medicaid |
$33,248.71
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$79,440.89
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$70,564.35 |
| Max. Negotiated Rate |
$79,440.89 |
| Rate for Payer: Anthem Medicaid |
$76,069.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$76,069.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76,069.03
|
| Rate for Payer: Dean Health Medicaid |
$76,069.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$70,564.35
|
| Rate for Payer: Managed Health Services Medicaid |
$79,440.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$76,069.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$76,069.03
|
| Rate for Payer: United Healthcare Medicaid |
$76,069.03
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$55,152.67
|
|
|
Service Code
|
APR-DRG 3033
|
| Min. Negotiated Rate |
$48,990.04 |
| Max. Negotiated Rate |
$55,152.67 |
| Rate for Payer: Anthem Medicaid |
$52,811.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$52,811.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52,811.72
|
| Rate for Payer: Dean Health Medicaid |
$52,811.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$48,990.04
|
| Rate for Payer: Managed Health Services Medicaid |
$55,152.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$52,811.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52,811.72
|
| Rate for Payer: United Healthcare Medicaid |
$52,811.72
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$40,071.18
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$35,593.72 |
| Max. Negotiated Rate |
$40,071.18 |
| Rate for Payer: Anthem Medicaid |
$38,370.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$38,370.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38,370.36
|
| Rate for Payer: Dean Health Medicaid |
$38,370.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$35,593.72
|
| Rate for Payer: Managed Health Services Medicaid |
$40,071.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$38,370.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$38,370.36
|
| Rate for Payer: United Healthcare Medicaid |
$38,370.36
|
|
|
DORSAL BLOCKING SPLINT SMALL
|
Facility
|
IP
|
$769.00
|
|
| Hospital Charge Code |
2971619
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$391.88 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$479.86
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
