|
EP Study W/Ablation for V-Tach
|
Facility
|
IP
|
$10,627.00
|
|
|
Service Code
|
CPT 93654
|
| Hospital Charge Code |
3052517
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,207.23 |
| Max. Negotiated Rate |
$9,776.84 |
| Rate for Payer: Aetna Commercial |
$9,564.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,139.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,632.31
|
| Rate for Payer: Cash Price |
$3,188.10
|
| Rate for Payer: Cigna Commercial |
$9,776.84
|
| Rate for Payer: Health EOS Commercial |
$9,458.03
|
| Rate for Payer: HFN Commercial |
$9,776.84
|
| Rate for Payer: Multiplan Commercial |
$8,501.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,376.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,776.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,207.23
|
| Rate for Payer: Quartz Commercial |
$6,376.20
|
| Rate for Payer: WEA Trust Commercial |
$5,844.85
|
| Rate for Payer: WPS Commercial |
$7,871.42
|
|
|
EP Study W/Ablation for V-Tach
|
Facility
|
OP
|
$10,627.00
|
|
|
Service Code
|
CPT 93654
|
| Hospital Charge Code |
3052517
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,207.23 |
| Max. Negotiated Rate |
$93,900.28 |
| Rate for Payer: Aetna Commercial |
$9,564.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,139.22
|
| Rate for Payer: Aetna Managed Medicare |
$23,475.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$23,475.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,632.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23,475.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23,475.07
|
| Rate for Payer: Cash Price |
$3,188.10
|
| Rate for Payer: Cash Price |
$3,188.10
|
| Rate for Payer: Cash Price |
$3,188.10
|
| Rate for Payer: Cigna Commercial |
$9,776.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23,475.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,946.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23,475.07
|
| Rate for Payer: Health EOS Commercial |
$9,458.03
|
| Rate for Payer: HFN Commercial |
$9,776.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87,327.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23,475.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23,475.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23,475.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23,475.07
|
| Rate for Payer: Multiplan Commercial |
$8,501.60
|
| Rate for Payer: NAPHCARE Commercial |
$35,212.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,776.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,207.23
|
| Rate for Payer: Quartz Commercial |
$6,907.55
|
| Rate for Payer: Quartz Medicare Advantage |
$23,475.07
|
| Rate for Payer: The Alliance Commercial |
$93,900.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,475.07
|
| Rate for Payer: United Healthcare PPO |
$11,078.00
|
| Rate for Payer: WEA Trust Commercial |
$5,844.85
|
| Rate for Payer: Wellcare Medicare |
$23,475.07
|
| Rate for Payer: WPS Commercial |
$7,871.42
|
|
|
EP Study W/LA/CS Pacing & Recording +
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
CPT 93621
|
| Hospital Charge Code |
4125519
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$375.48 |
| Max. Negotiated Rate |
$29,139.00 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Aetna Managed Medicare |
$375.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$750.42
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,005.75
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$871.65
|
| Rate for Payer: Quartz Medicare Advantage |
$804.60
|
| Rate for Payer: The Alliance Commercial |
$5,364.00
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
EP Study W/LA/CS Pacing & Recording +
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
CPT 93621
|
| Hospital Charge Code |
4125519
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$657.09 |
| Max. Negotiated Rate |
$1,233.72 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$804.60
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
EP STUDY W/PULM VEIN ABLATION (PVI)-AF
|
Facility
|
OP
|
$15,470.00
|
|
|
Service Code
|
CPT 93656
|
| Hospital Charge Code |
5464771
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$7,580.30 |
| Max. Negotiated Rate |
$93,900.28 |
| Rate for Payer: Aetna Commercial |
$13,923.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,304.20
|
| Rate for Payer: Aetna Managed Medicare |
$23,475.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$23,475.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,199.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23,475.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23,475.07
|
| Rate for Payer: Cash Price |
$4,641.00
|
| Rate for Payer: Cash Price |
$4,641.00
|
| Rate for Payer: Cash Price |
$4,641.00
|
| Rate for Payer: Cigna Commercial |
$14,232.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23,475.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,657.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23,475.07
|
| Rate for Payer: Health EOS Commercial |
$13,768.30
|
| Rate for Payer: HFN Commercial |
$14,232.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87,327.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23,475.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23,475.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23,475.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23,475.07
|
| Rate for Payer: Multiplan Commercial |
$12,376.00
|
| Rate for Payer: NAPHCARE Commercial |
$35,212.60
|
| Rate for Payer: Preferred Network Access Commercial |
$14,232.40
|
| Rate for Payer: Quartz Beloit One Network |
$7,580.30
|
| Rate for Payer: Quartz Commercial |
$10,055.50
|
| Rate for Payer: Quartz Medicare Advantage |
$23,475.07
|
| Rate for Payer: The Alliance Commercial |
$93,900.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,475.07
|
| Rate for Payer: United Healthcare PPO |
$11,078.00
|
| Rate for Payer: WEA Trust Commercial |
$8,508.50
|
| Rate for Payer: Wellcare Medicare |
$23,475.07
|
| Rate for Payer: WPS Commercial |
$11,458.63
|
|
|
EP STUDY W/PULM VEIN ABLATION (PVI)-AF
|
Facility
|
IP
|
$15,470.00
|
|
|
Service Code
|
CPT 93656
|
| Hospital Charge Code |
5464771
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$7,580.30 |
| Max. Negotiated Rate |
$14,232.40 |
| Rate for Payer: Aetna Commercial |
$13,923.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,304.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,199.10
|
| Rate for Payer: Cash Price |
$4,641.00
|
| Rate for Payer: Cigna Commercial |
$14,232.40
|
| Rate for Payer: Health EOS Commercial |
$13,768.30
|
| Rate for Payer: HFN Commercial |
$14,232.40
|
| Rate for Payer: Multiplan Commercial |
$12,376.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,282.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,232.40
|
| Rate for Payer: Quartz Beloit One Network |
$7,580.30
|
| Rate for Payer: Quartz Commercial |
$9,282.00
|
| Rate for Payer: WEA Trust Commercial |
$8,508.50
|
| Rate for Payer: WPS Commercial |
$11,458.63
|
|
|
Erbitux 10 mg Charge
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
2958945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.49 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.49
|
| Rate for Payer: Health EOS Commercial |
$225.68
|
| Rate for Payer: HFN Commercial |
$235.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.15
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Preferred Network Access Commercial |
$235.60
|
| Rate for Payer: Quartz Beloit One Network |
$109.12
|
| Rate for Payer: Quartz Commercial |
$141.36
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: United Healthcare Medicaid |
$73.49
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.72
|
|
|
Erbitux 10 mg Charge
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
2958945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.72 |
| Max. Negotiated Rate |
$294.88 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$73.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$161.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$119.04
|
| Rate for Payer: Anthem Medicare Advantage |
$73.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$73.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$73.72
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$73.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$73.72
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$274.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$73.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$73.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$73.72
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$110.58
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$73.72
|
| Rate for Payer: The Alliance Commercial |
$294.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.72
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: Wellcare Medicare |
$73.72
|
| Rate for Payer: WPS Commercial |
$183.72
|
|
|
Erbitux 10 mg Charge
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
2958945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$148.80
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
Ertapenem 1gm vial [Med]
|
Facility
|
OP
|
$1,159.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
2974935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.74 |
| Max. Negotiated Rate |
$4,636.00 |
| Rate for Payer: Aetna Commercial |
$1,043.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$996.74
|
| Rate for Payer: Aetna Managed Medicare |
$324.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$753.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$579.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.27
|
| Rate for Payer: Cash Price |
$347.70
|
| Rate for Payer: Cash Price |
$347.70
|
| Rate for Payer: Cigna Commercial |
$1,066.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.74
|
| Rate for Payer: Health EOS Commercial |
$1,031.51
|
| Rate for Payer: HFN Commercial |
$1,066.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$869.25
|
| Rate for Payer: Multiplan Commercial |
$927.20
|
| Rate for Payer: NAPHCARE Commercial |
$695.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.28
|
| Rate for Payer: Quartz Beloit One Network |
$567.91
|
| Rate for Payer: Quartz Commercial |
$753.35
|
| Rate for Payer: Quartz Medicare Advantage |
$695.40
|
| Rate for Payer: The Alliance Commercial |
$4,636.00
|
| Rate for Payer: WEA Trust Commercial |
$637.45
|
| Rate for Payer: WPS Commercial |
$29.74
|
|
|
Ertapenem 1gm vial [Med]
|
Facility
|
IP
|
$1,159.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
2974935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$567.91 |
| Max. Negotiated Rate |
$1,066.28 |
| Rate for Payer: Aetna Commercial |
$1,043.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$996.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.27
|
| Rate for Payer: Cash Price |
$347.70
|
| Rate for Payer: Cigna Commercial |
$1,066.28
|
| Rate for Payer: Health EOS Commercial |
$1,031.51
|
| Rate for Payer: HFN Commercial |
$1,066.28
|
| Rate for Payer: Multiplan Commercial |
$927.20
|
| Rate for Payer: NAPHCARE Commercial |
$695.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.28
|
| Rate for Payer: Quartz Beloit One Network |
$567.91
|
| Rate for Payer: Quartz Commercial |
$695.40
|
| Rate for Payer: WEA Trust Commercial |
$637.45
|
| Rate for Payer: WPS Commercial |
$858.47
|
|
|
Erythrocytosis Evaluation
|
Facility
|
IP
|
$3,789.00
|
|
|
Service Code
|
CPT 82820
|
| Hospital Charge Code |
3135500
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,856.61 |
| Max. Negotiated Rate |
$3,485.88 |
| Rate for Payer: Aetna Commercial |
$3,410.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,258.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,008.17
|
| Rate for Payer: Cash Price |
$1,136.70
|
| Rate for Payer: Cigna Commercial |
$3,485.88
|
| Rate for Payer: Health EOS Commercial |
$3,372.21
|
| Rate for Payer: HFN Commercial |
$3,485.88
|
| Rate for Payer: Multiplan Commercial |
$3,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,273.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,485.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,856.61
|
| Rate for Payer: Quartz Commercial |
$2,273.40
|
| Rate for Payer: WEA Trust Commercial |
$2,083.95
|
| Rate for Payer: WPS Commercial |
$2,806.51
|
|
|
Erythrocytosis Evaluation
|
Facility
|
OP
|
$3,789.00
|
|
|
Service Code
|
CPT 82820
|
| Hospital Charge Code |
3135500
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$3,485.88 |
| Rate for Payer: Aetna Commercial |
$3,410.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,258.54
|
| Rate for Payer: Aetna Managed Medicare |
$13.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.14
|
| Rate for Payer: Anthem Medicaid |
$13.78
|
| Rate for Payer: Anthem Medicare Advantage |
$13.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,008.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.34
|
| Rate for Payer: Cash Price |
$1,136.70
|
| Rate for Payer: Cash Price |
$1,136.70
|
| Rate for Payer: Cigna Commercial |
$3,485.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,120.32
|
| Rate for Payer: Dean Health Medicaid |
$13.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.34
|
| Rate for Payer: Health EOS Commercial |
$3,372.21
|
| Rate for Payer: HFN Commercial |
$3,485.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.34
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.34
|
| Rate for Payer: Managed Health Services Medicaid |
$14.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.34
|
| Rate for Payer: Multiplan Commercial |
$3,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.01
|
| Rate for Payer: Preferred Network Access Commercial |
$3,485.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,856.61
|
| Rate for Payer: Quartz Commercial |
$2,462.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13.34
|
| Rate for Payer: The Alliance Commercial |
$53.36
|
| Rate for Payer: United Healthcare Medicaid |
$13.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.34
|
| Rate for Payer: United Healthcare PPO |
$2,841.75
|
| Rate for Payer: WEA Trust Commercial |
$2,083.95
|
| Rate for Payer: Wellcare Medicare |
$13.34
|
| Rate for Payer: WMAP Medicaid |
$13.78
|
| Rate for Payer: WPS Commercial |
$2,806.51
|
|
|
Erythrocytosis Evaluation
|
Professional
|
Both
|
$3,789.00
|
|
|
Service Code
|
CPT 82820
|
| Hospital Charge Code |
3135500
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$3,599.55 |
| Rate for Payer: Aetna Commercial |
$3,599.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,258.54
|
| Rate for Payer: Cash Price |
$1,136.70
|
| Rate for Payer: Cash Price |
$1,136.70
|
| Rate for Payer: Cigna Commercial |
$3,599.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,894.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,273.40
|
| Rate for Payer: Health EOS Commercial |
$3,447.99
|
| Rate for Payer: HFN Commercial |
$3,599.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.09
|
| Rate for Payer: Multiplan Commercial |
$3,031.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,599.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,667.16
|
| Rate for Payer: Quartz Commercial |
$2,159.73
|
| Rate for Payer: The Alliance Commercial |
$1,894.50
|
| Rate for Payer: WEA Trust Commercial |
$2,083.95
|
| Rate for Payer: WPS Commercial |
$2,806.51
|
|
|
Erythropoietin Level
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
977936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$354.20 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Aetna Managed Medicare |
$18.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.19
|
| Rate for Payer: Anthem Medicaid |
$19.42
|
| Rate for Payer: Anthem Medicare Advantage |
$18.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.79
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.45
|
| Rate for Payer: Dean Health Medicaid |
$19.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.79
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.79
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.79
|
| Rate for Payer: Managed Health Services Medicaid |
$20.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.79
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$28.18
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.42
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$250.25
|
| Rate for Payer: Quartz Medicare Advantage |
$18.79
|
| Rate for Payer: The Alliance Commercial |
$75.16
|
| Rate for Payer: United Healthcare Medicaid |
$19.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.79
|
| Rate for Payer: United Healthcare PPO |
$288.75
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: Wellcare Medicare |
$18.79
|
| Rate for Payer: WMAP Medicaid |
$19.42
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Erythropoietin Level
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
977936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.33 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$365.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.00
|
| Rate for Payer: Health EOS Commercial |
$350.35
|
| Rate for Payer: HFN Commercial |
$365.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.33
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: Preferred Network Access Commercial |
$365.75
|
| Rate for Payer: Quartz Beloit One Network |
$169.40
|
| Rate for Payer: Quartz Commercial |
$219.45
|
| Rate for Payer: The Alliance Commercial |
$192.50
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Erythropoietin Level
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
977936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$188.65 |
| Max. Negotiated Rate |
$354.20 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$231.00
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$231.00
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Escitalopram Lvl
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$103.04 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$67.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$67.20
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
Escitalopram Lvl
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$106.40 |
| Rate for Payer: Aetna Commercial |
$106.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$106.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.20
|
| Rate for Payer: Health EOS Commercial |
$101.92
|
| Rate for Payer: HFN Commercial |
$106.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: Preferred Network Access Commercial |
$106.40
|
| Rate for Payer: Quartz Beloit One Network |
$49.28
|
| Rate for Payer: Quartz Commercial |
$63.84
|
| Rate for Payer: The Alliance Commercial |
$56.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
Escitalopram Lvl
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040879
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$103.04 |
| Rate for Payer: Aetna Commercial |
$100.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.32
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$103.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.68
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$99.68
|
| Rate for Payer: HFN Commercial |
$103.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$89.60
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$103.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$54.88
|
| Rate for Payer: Quartz Commercial |
$72.80
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$61.60
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$82.96
|
|
|
ESMARK BANDAGE 4INX9 FT STERILE DYNJ05916H (SUB)/961650 (SUB)
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
4858710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
ESMARK BANDAGE 4INX9 FT STERILE DYNJ05916H (SUB)/961650 (SUB)
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
4858710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$35.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.95
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.75
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$75.00
|
| Rate for Payer: The Alliance Commercial |
$500.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
ESMARK BANDAGE 4X12 LF DYNJ05917/DYNJ05117AH (SUB)
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
3911538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
ESMARK BANDAGE 4X12 LF DYNJ05917/DYNJ05117AH (SUB)
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
3911538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
ESMARK BANDAGE 6 IN DYNJ05919/DYNJ05918 (SUB)/TRN99304 (SUB)
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2965841
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
