|
Annual depression screening, 15 minutes G0444
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS G0444
|
| Hospital Charge Code |
5472856
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.60
|
| Rate for Payer: Health EOS Commercial |
$23.66
|
| Rate for Payer: HFN Commercial |
$24.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.81
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$24.70
|
| Rate for Payer: Quartz Beloit One Network |
$11.44
|
| Rate for Payer: Quartz Commercial |
$14.82
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Annual Wellness Visit Initial
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
1122841
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$569.39 |
| Rate for Payer: Aetna Commercial |
$356.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$356.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$187.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.00
|
| Rate for Payer: Health EOS Commercial |
$341.25
|
| Rate for Payer: HFN Commercial |
$356.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$569.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$569.39
|
| Rate for Payer: Multiplan Commercial |
$300.00
|
| Rate for Payer: Preferred Network Access Commercial |
$356.25
|
| Rate for Payer: Quartz Beloit One Network |
$165.00
|
| Rate for Payer: Quartz Commercial |
$213.75
|
| Rate for Payer: The Alliance Commercial |
$187.50
|
| Rate for Payer: WEA Trust Commercial |
$206.25
|
| Rate for Payer: WPS Commercial |
$277.76
|
|
|
Annual Wellness Visit Subsequent
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
1122842
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$447.75 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.00
|
| Rate for Payer: Health EOS Commercial |
$182.00
|
| Rate for Payer: HFN Commercial |
$190.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$447.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$447.75
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: Preferred Network Access Commercial |
$190.00
|
| Rate for Payer: Quartz Beloit One Network |
$88.00
|
| Rate for Payer: Quartz Commercial |
$114.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
ANNULOPLASTY BAND 23MM DURAN 620BG23
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 23MM DURAN 620BG23
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973891
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 25MM DURAN 620BG25
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 25MM DURAN 620BG25
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 27MM DURAN 620BG27
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 27MM DURAN 620BG27
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973893
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 29MM DURAN 620BG29
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 29MM DURAN 620BG29
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 31MM DURAN 620BG31
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973895
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 31MM DURAN 620BG31
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973895
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 33MM DURAN 620BG33
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY BAND 33MM DURAN 620BG33
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 23MM DURAN #620RG23
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 23MM DURAN #620RG23
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 25MM DURAN #620RG25
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973885
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 25MM DURAN #620RG25
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973885
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 27MM DURAN #620RG27
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 27MM DURAN #620RG27
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 29MM DURAN #620RG29
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 29MM DURAN #620RG29
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 31MM DURAN #620RG31
|
Facility
|
OP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,416.56 |
| Max. Negotiated Rate |
$48,808.00 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,416.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,931.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,856.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,828.24
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,151.50
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,931.30
|
| Rate for Payer: Quartz Medicare Advantage |
$7,321.20
|
| Rate for Payer: The Alliance Commercial |
$48,808.00
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
|
ANNULOPLASTY RING 31MM DURAN #620RG31
|
Facility
|
IP
|
$12,202.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,978.98 |
| Max. Negotiated Rate |
$11,225.84 |
| Rate for Payer: Aetna Commercial |
$10,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,493.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,467.06
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,225.84
|
| Rate for Payer: Health EOS Commercial |
$10,859.78
|
| Rate for Payer: HFN Commercial |
$11,225.84
|
| Rate for Payer: Multiplan Commercial |
$9,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,225.84
|
| Rate for Payer: Quartz Beloit One Network |
$5,978.98
|
| Rate for Payer: Quartz Commercial |
$7,321.20
|
| Rate for Payer: WEA Trust Commercial |
$6,711.10
|
| Rate for Payer: WPS Commercial |
$9,038.02
|
|
