|
GD Amplification
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Amplification
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Amplification
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD DNA Isolation
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD DNA Isolation
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD DNA Isolation
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Enzyme Digestion
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Enzyme Digestion
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Enzyme Digestion
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Interp & Report
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Interp & Report
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Interp & Report
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Mutation ID
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Mutation ID
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Mutation ID
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Separation
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Aetna Managed Medicare |
$10.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.71
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$24.05
|
| Rate for Payer: Quartz Medicare Advantage |
$22.20
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: United Healthcare PPO |
$27.75
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Separation
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$33.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.61
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$34.04
|
| Rate for Payer: Health EOS Commercial |
$32.93
|
| Rate for Payer: HFN Commercial |
$34.04
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$34.04
|
| Rate for Payer: Quartz Beloit One Network |
$18.13
|
| Rate for Payer: Quartz Commercial |
$22.20
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
GD Separation
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$35.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.20
|
| Rate for Payer: Health EOS Commercial |
$33.67
|
| Rate for Payer: HFN Commercial |
$35.15
|
| Rate for Payer: Multiplan Commercial |
$29.60
|
| Rate for Payer: Preferred Network Access Commercial |
$35.15
|
| Rate for Payer: Quartz Beloit One Network |
$16.28
|
| Rate for Payer: Quartz Commercial |
$21.09
|
| Rate for Payer: The Alliance Commercial |
$18.50
|
| Rate for Payer: WEA Trust Commercial |
$20.35
|
| Rate for Payer: WPS Commercial |
$27.41
|
|
|
Gel-1 1 Unit Charge
|
Facility
|
OP
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.29 |
| Max. Negotiated Rate |
$1,989.16 |
| Rate for Payer: Aetna Commercial |
$1,646.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,572.94
|
| Rate for Payer: Aetna Managed Medicare |
$497.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,188.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$914.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$877.92
|
| Rate for Payer: Anthem Medicare Advantage |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$969.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$497.29
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,682.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$497.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$691.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$497.29
|
| Rate for Payer: Health EOS Commercial |
$1,627.81
|
| Rate for Payer: HFN Commercial |
$1,682.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,849.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$497.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$497.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$497.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$497.29
|
| Rate for Payer: Multiplan Commercial |
$1,463.20
|
| Rate for Payer: NAPHCARE Commercial |
$745.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,682.68
|
| Rate for Payer: Quartz Beloit One Network |
$896.21
|
| Rate for Payer: Quartz Commercial |
$1,188.85
|
| Rate for Payer: Quartz Medicare Advantage |
$497.29
|
| Rate for Payer: The Alliance Commercial |
$1,989.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$497.29
|
| Rate for Payer: WEA Trust Commercial |
$1,005.95
|
| Rate for Payer: Wellcare Medicare |
$497.29
|
| Rate for Payer: WPS Commercial |
$1,305.93
|
|
|
Gel-1 1 Unit Charge
|
Professional
|
Both
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.29 |
| Max. Negotiated Rate |
$1,737.55 |
| Rate for Payer: Aetna Commercial |
$1,737.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,572.94
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,737.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$497.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$522.37
|
| Rate for Payer: Health EOS Commercial |
$1,664.39
|
| Rate for Payer: HFN Commercial |
$1,737.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$784.55
|
| Rate for Payer: Multiplan Commercial |
$1,463.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,737.55
|
| Rate for Payer: Quartz Beloit One Network |
$804.76
|
| Rate for Payer: Quartz Commercial |
$1,042.53
|
| Rate for Payer: The Alliance Commercial |
$914.50
|
| Rate for Payer: United Healthcare Medicaid |
$497.29
|
| Rate for Payer: WEA Trust Commercial |
$1,005.95
|
| Rate for Payer: WPS Commercial |
$1,305.93
|
|
|
Gel-1 1 Unit Charge
|
Facility
|
IP
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$896.21 |
| Max. Negotiated Rate |
$1,682.68 |
| Rate for Payer: Aetna Commercial |
$1,646.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,572.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$969.37
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,682.68
|
| Rate for Payer: Health EOS Commercial |
$1,627.81
|
| Rate for Payer: HFN Commercial |
$1,682.68
|
| Rate for Payer: Multiplan Commercial |
$1,463.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,097.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,682.68
|
| Rate for Payer: Quartz Beloit One Network |
$896.21
|
| Rate for Payer: Quartz Commercial |
$1,097.40
|
| Rate for Payer: WEA Trust Commercial |
$1,005.95
|
| Rate for Payer: WPS Commercial |
$1,354.74
|
|
|
GEL AQUASONIC 20 GRAM 01-01 (OR SUPPLY)
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2965791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
GEL AQUASONIC 20 GRAM 01-01 (OR SUPPLY)
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2965791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Gelatein 20
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
3031434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Gelatein 20
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
3031434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
