|
LIP WEDGE RESECTION/LOWER
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960204
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
Lisdexamfetamine as Metabolite, Urine
|
Facility
|
IP
|
$333.00
|
|
| Hospital Charge Code |
4378679
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.70 |
| Max. Negotiated Rate |
$318.61 |
| Rate for Payer: Aetna Commercial |
$311.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$297.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.55
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$318.61
|
| Rate for Payer: Health EOS Commercial |
$308.22
|
| Rate for Payer: HFN Commercial |
$318.61
|
| Rate for Payer: Multiplan Commercial |
$277.06
|
| Rate for Payer: Preferred Network Access Commercial |
$318.61
|
| Rate for Payer: Quartz Beloit One Network |
$169.70
|
| Rate for Payer: Quartz Commercial |
$207.79
|
| Rate for Payer: WEA Trust Commercial |
$190.48
|
| Rate for Payer: WPS Commercial |
$256.51
|
|
|
Lisdexamfetamine as Metabolite, Urine
|
Professional
|
Both
|
$333.00
|
|
| Hospital Charge Code |
4378679
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$152.38 |
| Max. Negotiated Rate |
$329.00 |
| Rate for Payer: Aetna Commercial |
$329.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$297.84
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$329.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.79
|
| Rate for Payer: Health EOS Commercial |
$315.15
|
| Rate for Payer: HFN Commercial |
$329.00
|
| Rate for Payer: Multiplan Commercial |
$277.06
|
| Rate for Payer: Preferred Network Access Commercial |
$329.00
|
| Rate for Payer: Quartz Beloit One Network |
$152.38
|
| Rate for Payer: Quartz Commercial |
$197.40
|
| Rate for Payer: The Alliance Commercial |
$173.16
|
| Rate for Payer: WEA Trust Commercial |
$190.48
|
| Rate for Payer: WPS Commercial |
$256.51
|
|
|
Lisdexamfetamine as Metabolite, Urine
|
Facility
|
OP
|
$333.00
|
|
| Hospital Charge Code |
4378679
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.97 |
| Max. Negotiated Rate |
$318.61 |
| Rate for Payer: Aetna Commercial |
$311.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$297.84
|
| Rate for Payer: Aetna Managed Medicare |
$96.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.55
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cigna Commercial |
$318.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.81
|
| Rate for Payer: Health EOS Commercial |
$308.22
|
| Rate for Payer: HFN Commercial |
$318.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.74
|
| Rate for Payer: Multiplan Commercial |
$277.06
|
| Rate for Payer: NAPHCARE Commercial |
$207.79
|
| Rate for Payer: Preferred Network Access Commercial |
$318.61
|
| Rate for Payer: Quartz Beloit One Network |
$169.70
|
| Rate for Payer: Quartz Commercial |
$225.11
|
| Rate for Payer: Quartz Medicare Advantage |
$207.79
|
| Rate for Payer: The Alliance Commercial |
$173.16
|
| Rate for Payer: United Healthcare PPO |
$259.74
|
| Rate for Payer: WEA Trust Commercial |
$190.48
|
| Rate for Payer: WPS Commercial |
$256.51
|
|
|
Lithium Level
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
633778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$187.72 |
| Rate for Payer: Aetna Commercial |
$187.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$187.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$179.82
|
| Rate for Payer: HFN Commercial |
$187.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$187.72
|
| Rate for Payer: Quartz Beloit One Network |
$86.94
|
| Rate for Payer: Quartz Commercial |
$112.63
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: WPS Commercial |
$30.25
|
|
|
Lithium Level
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
633778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$181.79 |
| Rate for Payer: Aetna Commercial |
$177.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.41
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$181.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$175.86
|
| Rate for Payer: HFN Commercial |
$181.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$181.79
|
| Rate for Payer: Quartz Beloit One Network |
$96.82
|
| Rate for Payer: Quartz Commercial |
$128.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: United Healthcare PPO |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: Wellcare Medicare |
$6.87
|
| Rate for Payer: WPS Commercial |
$146.36
|
|
|
Lithium Level
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
633778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.82 |
| Max. Negotiated Rate |
$181.79 |
| Rate for Payer: Aetna Commercial |
$177.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.73
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$181.79
|
| Rate for Payer: Health EOS Commercial |
$175.86
|
| Rate for Payer: HFN Commercial |
$181.79
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: Preferred Network Access Commercial |
$181.79
|
| Rate for Payer: Quartz Beloit One Network |
$96.82
|
| Rate for Payer: Quartz Commercial |
$118.56
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: WPS Commercial |
$146.36
|
|
|
LITHOLAPAXY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960205
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
LITHOLAPAXY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960205
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)
|
Facility
|
OP
|
$14,838.60
|
|
|
Service Code
|
CPT 52318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,709.65 |
| Max. Negotiated Rate |
$14,838.60 |
| Rate for Payer: Aetna Managed Medicare |
$3,709.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,709.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,799.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,709.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,709.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,709.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,709.65
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.65
|
| Rate for Payer: The Alliance Commercial |
$14,838.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,709.65
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,709.65
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)
|
Facility
|
OP
|
$14,838.60
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,709.65 |
| Max. Negotiated Rate |
$14,838.60 |
| Rate for Payer: Aetna Managed Medicare |
$3,709.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,709.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,799.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,709.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,709.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,709.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,709.65
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.65
|
| Rate for Payer: The Alliance Commercial |
$14,838.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,709.65
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,709.65
|
|
|
Lithotripsy, extracorporeal shock wave
|
Facility
|
OP
|
$19,394.96
|
|
|
Service Code
|
CPT 50590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,709.65 |
| Max. Negotiated Rate |
$19,394.96 |
| Rate for Payer: Aetna Managed Medicare |
$3,709.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,394.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,336.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,619.84
|
| Rate for Payer: Anthem Medicare Advantage |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,709.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,799.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,709.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,709.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,709.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,709.65
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.65
|
| Rate for Payer: The Alliance Commercial |
$14,838.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,709.65
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,709.65
|
|
|
Liver Elastography W/O Imag W/I&R 91200
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 91200
|
| Hospital Charge Code |
5268661
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$133.79 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$33.45
|
| Rate for Payer: Anthem Medicare Advantage |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.45
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.45
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.45
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$50.17
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$33.45
|
| Rate for Payer: The Alliance Commercial |
$83.62
|
| Rate for Payer: United Healthcare Medicaid |
$22.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.45
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$133.79
|
|
|
Liver Elastography W/O Imag W/I&R 9120026
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 91200 26
|
| Hospital Charge Code |
5268662
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$11.04
|
| Rate for Payer: Anthem Medicare Advantage |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.04
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.04
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$16.57
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$11.04
|
| Rate for Payer: The Alliance Commercial |
$27.61
|
| Rate for Payer: United Healthcare Medicaid |
$10.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.04
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$44.18
|
|
|
Liver Fibrosis, Fibro Test-Acti Test Panel
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
CPT 81596
|
| Hospital Charge Code |
4506908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.08 |
| Max. Negotiated Rate |
$385.32 |
| Rate for Payer: Aetna Commercial |
$385.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$75.08
|
| Rate for Payer: Anthem Medicare Advantage |
$75.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.08
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$385.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$369.10
|
| Rate for Payer: HFN Commercial |
$385.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$265.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.08
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$112.62
|
| Rate for Payer: Preferred Network Access Commercial |
$385.32
|
| Rate for Payer: Quartz Beloit One Network |
$178.46
|
| Rate for Payer: Quartz Commercial |
$231.19
|
| Rate for Payer: Quartz Medicare Advantage |
$75.08
|
| Rate for Payer: The Alliance Commercial |
$296.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.08
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$330.34
|
|
|
Liver Fibrosis, Fibro Test-Acti Test Panel
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
CPT 81596
|
| Hospital Charge Code |
4506908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
Liver Fibrosis, Fibro Test-Acti Test Panel
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
CPT 81596
|
| Hospital Charge Code |
4506908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.08 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$75.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$281.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.39
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$124.63
|
| Rate for Payer: Anthem Medicare Advantage |
$75.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.08
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$279.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.08
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$112.62
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$263.64
|
| Rate for Payer: Quartz Medicare Advantage |
$75.08
|
| Rate for Payer: The Alliance Commercial |
$300.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.08
|
| Rate for Payer: United Healthcare PPO |
$304.20
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: Wellcare Medicare |
$75.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
Liver Kidney Microsome (LKM-1) Antibody, IgG
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
983305
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$213.41 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Aetna Managed Medicare |
$15.13
|
| Rate for Payer: Anthem Medicare Advantage |
$15.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.13
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$213.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.13
|
| Rate for Payer: Health EOS Commercial |
$204.42
|
| Rate for Payer: HFN Commercial |
$213.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: NAPHCARE Commercial |
$22.70
|
| Rate for Payer: Preferred Network Access Commercial |
$213.41
|
| Rate for Payer: Quartz Beloit One Network |
$98.84
|
| Rate for Payer: Quartz Commercial |
$128.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15.13
|
| Rate for Payer: The Alliance Commercial |
$59.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.13
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$66.58
|
|
|
Liver Kidney Microsome (LKM-1) Antibody, IgG
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
983305
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.07 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$202.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.06
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: Health EOS Commercial |
$199.93
|
| Rate for Payer: HFN Commercial |
$206.67
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: Preferred Network Access Commercial |
$206.67
|
| Rate for Payer: Quartz Beloit One Network |
$110.07
|
| Rate for Payer: Quartz Commercial |
$134.78
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
Liver Kidney Microsome (LKM-1) Antibody, IgG
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
983305
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$202.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.19
|
| Rate for Payer: Aetna Managed Medicare |
$15.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.12
|
| Rate for Payer: Anthem Medicare Advantage |
$15.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.13
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna Commercial |
$206.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.13
|
| Rate for Payer: Health EOS Commercial |
$199.93
|
| Rate for Payer: HFN Commercial |
$206.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$179.71
|
| Rate for Payer: NAPHCARE Commercial |
$22.70
|
| Rate for Payer: Preferred Network Access Commercial |
$206.67
|
| Rate for Payer: Quartz Beloit One Network |
$110.07
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: Quartz Medicare Advantage |
$15.13
|
| Rate for Payer: The Alliance Commercial |
$60.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.13
|
| Rate for Payer: United Healthcare PPO |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$123.55
|
| Rate for Payer: Wellcare Medicare |
$15.13
|
| Rate for Payer: WPS Commercial |
$166.38
|
|
|
LIVER RESECTION
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960206
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,298.75 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,298.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,014.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,478.80
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.04
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.04
|
| Rate for Payer: The Alliance Commercial |
$2,319.20
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
LIVER RESECTION
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960206
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$61,904.27
|
|
|
Service Code
|
APR-DRG 0012
|
| Min. Negotiated Rate |
$54,987.23 |
| Max. Negotiated Rate |
$61,904.27 |
| Rate for Payer: Anthem Medicaid |
$59,276.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$59,276.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59,276.75
|
| Rate for Payer: Dean Health Medicaid |
$59,276.75
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$54,987.23
|
| Rate for Payer: Managed Health Services Medicaid |
$61,904.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$59,276.75
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$59,276.75
|
| Rate for Payer: United Healthcare Medicaid |
$59,276.75
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$54,363.52
|
|
|
Service Code
|
APR-DRG 0011
|
| Min. Negotiated Rate |
$48,289.07 |
| Max. Negotiated Rate |
$54,363.52 |
| Rate for Payer: Anthem Medicaid |
$52,056.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$52,056.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52,056.07
|
| Rate for Payer: Dean Health Medicaid |
$52,056.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$48,289.07
|
| Rate for Payer: Managed Health Services Medicaid |
$54,363.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$52,056.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52,056.07
|
| Rate for Payer: United Healthcare Medicaid |
$52,056.07
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$80,142.35
|
|
|
Service Code
|
APR-DRG 0013
|
| Min. Negotiated Rate |
$71,187.44 |
| Max. Negotiated Rate |
$80,142.35 |
| Rate for Payer: Anthem Medicaid |
$76,740.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$76,740.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76,740.72
|
| Rate for Payer: Dean Health Medicaid |
$76,740.72
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$71,187.44
|
| Rate for Payer: Managed Health Services Medicaid |
$80,142.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$76,740.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$76,740.72
|
| Rate for Payer: United Healthcare Medicaid |
$76,740.72
|
|
