|
Export Aspiration 6Fr
|
Facility
|
OP
|
$5,768.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
2549084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,679.64 |
| Max. Negotiated Rate |
$5,518.82 |
| Rate for Payer: Aetna Commercial |
$5,398.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,679.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,899.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,999.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,879.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,179.32
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,518.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,356.98
|
| Rate for Payer: Health EOS Commercial |
$5,338.86
|
| Rate for Payer: HFN Commercial |
$5,518.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,499.04
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,599.23
|
| Rate for Payer: Preferred Network Access Commercial |
$5,518.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,939.37
|
| Rate for Payer: Quartz Commercial |
$3,899.17
|
| Rate for Payer: Quartz Medicare Advantage |
$3,599.23
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
Export Aspiration 6Fr
|
Professional
|
Both
|
$5,768.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
2549084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,639.44 |
| Max. Negotiated Rate |
$5,698.78 |
| Rate for Payer: Aetna Commercial |
$5,698.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,698.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,999.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,599.23
|
| Rate for Payer: Health EOS Commercial |
$5,458.84
|
| Rate for Payer: HFN Commercial |
$5,698.78
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,639.44
|
| Rate for Payer: Quartz Commercial |
$3,419.27
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
Export Aspiration 7Fr
|
Facility
|
IP
|
$5,768.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
2549086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,939.37 |
| Max. Negotiated Rate |
$5,518.82 |
| Rate for Payer: Aetna Commercial |
$5,398.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,179.32
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,518.82
|
| Rate for Payer: Health EOS Commercial |
$5,338.86
|
| Rate for Payer: HFN Commercial |
$5,518.82
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,518.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,939.37
|
| Rate for Payer: Quartz Commercial |
$3,599.23
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
Export Aspiration 7Fr
|
Facility
|
OP
|
$5,768.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
2549086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,679.64 |
| Max. Negotiated Rate |
$5,518.82 |
| Rate for Payer: Aetna Commercial |
$5,398.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,679.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,899.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,999.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,879.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,179.32
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,518.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,356.98
|
| Rate for Payer: Health EOS Commercial |
$5,338.86
|
| Rate for Payer: HFN Commercial |
$5,518.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,499.04
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,599.23
|
| Rate for Payer: Preferred Network Access Commercial |
$5,518.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,939.37
|
| Rate for Payer: Quartz Commercial |
$3,899.17
|
| Rate for Payer: Quartz Medicare Advantage |
$3,599.23
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
Export Aspiration 7Fr
|
Professional
|
Both
|
$5,768.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
2549086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,639.44 |
| Max. Negotiated Rate |
$5,698.78 |
| Rate for Payer: Aetna Commercial |
$5,698.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,698.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,999.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,599.23
|
| Rate for Payer: Health EOS Commercial |
$5,458.84
|
| Rate for Payer: HFN Commercial |
$5,698.78
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,698.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,639.44
|
| Rate for Payer: Quartz Commercial |
$3,419.27
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
Express Renal Stent
|
Facility
|
IP
|
$6,883.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4606631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,507.58 |
| Max. Negotiated Rate |
$6,585.65 |
| Rate for Payer: Aetna Commercial |
$6,442.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,156.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,793.91
|
| Rate for Payer: Cash Price |
$2,064.90
|
| Rate for Payer: Cigna Commercial |
$6,585.65
|
| Rate for Payer: Health EOS Commercial |
$6,370.90
|
| Rate for Payer: HFN Commercial |
$6,585.65
|
| Rate for Payer: Multiplan Commercial |
$5,726.66
|
| Rate for Payer: Preferred Network Access Commercial |
$6,585.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,507.58
|
| Rate for Payer: Quartz Commercial |
$4,294.99
|
| Rate for Payer: WEA Trust Commercial |
$3,937.08
|
| Rate for Payer: WPS Commercial |
$5,301.97
|
|
|
Express Renal Stent
|
Facility
|
OP
|
$6,883.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
4606631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,004.33 |
| Max. Negotiated Rate |
$6,585.65 |
| Rate for Payer: Aetna Commercial |
$6,442.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,156.16
|
| Rate for Payer: Aetna Managed Medicare |
$2,004.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,652.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,579.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,435.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,793.91
|
| Rate for Payer: Cash Price |
$2,064.90
|
| Rate for Payer: Cigna Commercial |
$6,585.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,005.91
|
| Rate for Payer: Health EOS Commercial |
$6,370.90
|
| Rate for Payer: HFN Commercial |
$6,585.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,368.74
|
| Rate for Payer: Multiplan Commercial |
$5,726.66
|
| Rate for Payer: NAPHCARE Commercial |
$4,294.99
|
| Rate for Payer: Preferred Network Access Commercial |
$6,585.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,507.58
|
| Rate for Payer: Quartz Commercial |
$4,652.91
|
| Rate for Payer: Quartz Medicare Advantage |
$4,294.99
|
| Rate for Payer: The Alliance Commercial |
$3,579.16
|
| Rate for Payer: WEA Trust Commercial |
$3,937.08
|
| Rate for Payer: WPS Commercial |
$5,301.97
|
|
|
EXTENDED EEG STUDIES
|
Facility
|
OP
|
$230.61
|
|
|
Service Code
|
EAPG 00210
|
| Min. Negotiated Rate |
$221.74 |
| Max. Negotiated Rate |
$230.61 |
| Rate for Payer: Anthem Medicaid |
$221.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$221.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$221.74
|
| Rate for Payer: Dean Health Medicaid |
$221.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$221.74
|
| Rate for Payer: Managed Health Services Medicaid |
$230.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$221.74
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$221.74
|
| Rate for Payer: United Healthcare Medicaid |
$221.74
|
|
|
EXTENDER TIGHTROPE BUTTON AR-1589RT
|
Facility
|
OP
|
$2,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$697.13 |
| Max. Negotiated Rate |
$2,290.58 |
| Rate for Payer: Aetna Commercial |
$2,240.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,141.19
|
| Rate for Payer: Aetna Managed Medicare |
$697.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,618.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,244.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,195.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,319.57
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cigna Commercial |
$2,290.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,393.31
|
| Rate for Payer: Health EOS Commercial |
$2,215.89
|
| Rate for Payer: HFN Commercial |
$2,290.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,867.32
|
| Rate for Payer: Multiplan Commercial |
$1,991.81
|
| Rate for Payer: NAPHCARE Commercial |
$1,493.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,290.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.98
|
| Rate for Payer: Quartz Commercial |
$1,618.34
|
| Rate for Payer: Quartz Medicare Advantage |
$1,493.86
|
| Rate for Payer: The Alliance Commercial |
$1,244.88
|
| Rate for Payer: WEA Trust Commercial |
$1,369.37
|
| Rate for Payer: WPS Commercial |
$1,844.10
|
|
|
EXTENDER TIGHTROPE BUTTON AR-1589RT
|
Facility
|
IP
|
$2,394.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,219.98 |
| Max. Negotiated Rate |
$2,290.58 |
| Rate for Payer: Aetna Commercial |
$2,240.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,141.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,319.57
|
| Rate for Payer: Cash Price |
$718.20
|
| Rate for Payer: Cigna Commercial |
$2,290.58
|
| Rate for Payer: Health EOS Commercial |
$2,215.89
|
| Rate for Payer: HFN Commercial |
$2,290.58
|
| Rate for Payer: Multiplan Commercial |
$1,991.81
|
| Rate for Payer: Preferred Network Access Commercial |
$2,290.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.98
|
| Rate for Payer: Quartz Commercial |
$1,493.86
|
| Rate for Payer: WEA Trust Commercial |
$1,369.37
|
| Rate for Payer: WPS Commercial |
$1,844.10
|
|
|
EXTENSION LINE HPT200E
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2972326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$29.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.36
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.56
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$63.65
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$68.95
|
| Rate for Payer: Quartz Medicare Advantage |
$63.65
|
| Rate for Payer: The Alliance Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
EXTENSION LINE HPT200E
|
Facility
|
IP
|
$102.00
|
|
| Hospital Charge Code |
2972326
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
EXTENSION SET FILTER 1.2 MICRON 12354-05
|
Facility
|
IP
|
$110.00
|
|
| Hospital Charge Code |
4494206
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
EXTENSION SET FILTER 1.2 MICRON 12354-05
|
Facility
|
OP
|
$110.00
|
|
| Hospital Charge Code |
4494206
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
Extension Tubing
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
3040293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Extension Tubing
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
3040293
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Extension tubing with stopcock - Peripheral IV Equipment:
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
3003558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
Extension tubing with stopcock - Peripheral IV Equipment:
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
3003558
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
OP
|
$117.93
|
|
|
Service Code
|
EAPG 00860
|
| Min. Negotiated Rate |
$113.39 |
| Max. Negotiated Rate |
$117.93 |
| Rate for Payer: Anthem Medicaid |
$113.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$113.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.39
|
| Rate for Payer: Dean Health Medicaid |
$113.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$113.39
|
| Rate for Payer: Managed Health Services Medicaid |
$117.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.39
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$113.39
|
| Rate for Payer: United Healthcare Medicaid |
$113.39
|
|
|
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$16,396.74
|
|
|
Service Code
|
APR-DRG 9111
|
| Min. Negotiated Rate |
$14,564.61 |
| Max. Negotiated Rate |
$16,396.74 |
| Rate for Payer: Anthem Medicaid |
$15,700.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$15,700.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15,700.78
|
| Rate for Payer: Dean Health Medicaid |
$15,700.78
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14,564.61
|
| Rate for Payer: Managed Health Services Medicaid |
$16,396.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,700.78
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15,700.78
|
| Rate for Payer: United Healthcare Medicaid |
$15,700.78
|
|
|
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$56,730.97
|
|
|
Service Code
|
APR-DRG 9114
|
| Min. Negotiated Rate |
$50,391.98 |
| Max. Negotiated Rate |
$56,730.97 |
| Rate for Payer: Anthem Medicaid |
$54,323.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$54,323.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54,323.03
|
| Rate for Payer: Dean Health Medicaid |
$54,323.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50,391.98
|
| Rate for Payer: Managed Health Services Medicaid |
$56,730.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$54,323.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$54,323.03
|
| Rate for Payer: United Healthcare Medicaid |
$54,323.03
|
|
|
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$21,394.68
|
|
|
Service Code
|
APR-DRG 9112
|
| Min. Negotiated Rate |
$19,004.09 |
| Max. Negotiated Rate |
$21,394.68 |
| Rate for Payer: Anthem Medicaid |
$20,486.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20,486.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20,486.58
|
| Rate for Payer: Dean Health Medicaid |
$20,486.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19,004.09
|
| Rate for Payer: Managed Health Services Medicaid |
$21,394.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,486.58
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20,486.58
|
| Rate for Payer: United Healthcare Medicaid |
$20,486.58
|
|
|
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$32,793.48
|
|
|
Service Code
|
APR-DRG 9113
|
| Min. Negotiated Rate |
$29,129.21 |
| Max. Negotiated Rate |
$32,793.48 |
| Rate for Payer: Anthem Medicaid |
$31,401.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$31,401.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31,401.56
|
| Rate for Payer: Dean Health Medicaid |
$31,401.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$29,129.21
|
| Rate for Payer: Managed Health Services Medicaid |
$32,793.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$31,401.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$31,401.56
|
| Rate for Payer: United Healthcare Medicaid |
$31,401.56
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$84,166.16
|
|
|
Service Code
|
MSDRG 933
|
| Min. Negotiated Rate |
$30,329.33 |
| Max. Negotiated Rate |
$84,166.16 |
| Rate for Payer: Aetna Managed Medicare |
$30,329.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83,277.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63,831.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60,644.00
|
| Rate for Payer: Anthem Medicare Advantage |
$30,329.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,329.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,329.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,329.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67,320.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,329.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61,488.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,329.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,329.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,329.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,329.33
|
| Rate for Payer: NAPHCARE Commercial |
$45,494.00
|
| Rate for Payer: Quartz Medicare Advantage |
$30,329.33
|
| Rate for Payer: The Alliance Commercial |
$84,166.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,329.33
|
| Rate for Payer: United Healthcare PPO |
$47,869.94
|
| Rate for Payer: Wellcare Medicare |
$30,329.33
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT
|
Facility
|
IP
|
$729,135.68
|
|
|
Service Code
|
MSDRG 927
|
| Min. Negotiated Rate |
$164,013.10 |
| Max. Negotiated Rate |
$729,135.68 |
| Rate for Payer: Aetna Managed Medicare |
$164,013.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$402,132.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$308,231.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292,839.66
|
| Rate for Payer: Anthem Medicare Advantage |
$164,013.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$164,013.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$164,013.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$164,013.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$325,078.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$164,013.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$534,554.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164,013.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$164,013.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$164,013.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$164,013.10
|
| Rate for Payer: NAPHCARE Commercial |
$246,019.64
|
| Rate for Payer: Quartz Medicare Advantage |
$164,013.10
|
| Rate for Payer: The Alliance Commercial |
$729,135.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$164,013.10
|
| Rate for Payer: United Healthcare PPO |
$416,157.48
|
| Rate for Payer: Wellcare Medicare |
$164,013.10
|
|
