|
Lovenox 10 mg Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
2958914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Medicare Advantage |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.56
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.64
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$0.84
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$0.56
|
| Rate for Payer: The Alliance Commercial |
$1.54
|
| Rate for Payer: United Healthcare Medicaid |
$0.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.56
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$1.61
|
|
|
Lovenox 10 mg Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
2958914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.85
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$2.25
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$1.61
|
|
|
Low - Blood Glucose Hi/Lo
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Low - Blood Glucose Hi/Lo
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.70
|
| Rate for Payer: Anthem Medicare Advantage |
$5.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.24
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$7.86
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5.24
|
| Rate for Payer: The Alliance Commercial |
$20.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.24
|
| Rate for Payer: United Healthcare PPO |
$60.06
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: Wellcare Medicare |
$5.24
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
LOW COST SKIN SUBSTITUTE APP (add'l 100 sq cm) C5274
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS C5274
|
| Hospital Charge Code |
6242709
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.98 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.79
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
LOW COST SKIN SUBSTITUTE APP (up to 100 sq cm) C5273
|
Professional
|
Both
|
$369.00
|
|
|
Service Code
|
HCPCS C5273
|
| Hospital Charge Code |
6242708
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$168.85 |
| Max. Negotiated Rate |
$364.57 |
| Rate for Payer: Aetna Commercial |
$364.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.03
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$364.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.26
|
| Rate for Payer: Health EOS Commercial |
$349.22
|
| Rate for Payer: HFN Commercial |
$364.57
|
| Rate for Payer: Multiplan Commercial |
$307.01
|
| Rate for Payer: Preferred Network Access Commercial |
$364.57
|
| Rate for Payer: Quartz Beloit One Network |
$168.85
|
| Rate for Payer: Quartz Commercial |
$218.74
|
| Rate for Payer: The Alliance Commercial |
$191.88
|
| Rate for Payer: WEA Trust Commercial |
$211.07
|
| Rate for Payer: WPS Commercial |
$284.24
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$66,738.88
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$19,928.74 |
| Max. Negotiated Rate |
$66,738.88 |
| Rate for Payer: Aetna Managed Medicare |
$19,928.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55,335.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42,414.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40,296.40
|
| Rate for Payer: Anthem Medicare Advantage |
$19,928.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,928.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,928.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,928.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44,732.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,928.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48,706.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,928.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,928.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,928.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,928.74
|
| Rate for Payer: NAPHCARE Commercial |
$29,893.11
|
| Rate for Payer: Quartz Medicare Advantage |
$19,928.74
|
| Rate for Payer: The Alliance Commercial |
$66,738.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,928.74
|
| Rate for Payer: United Healthcare PPO |
$37,918.62
|
| Rate for Payer: Wellcare Medicare |
$19,928.74
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$96,058.56
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$28,624.61 |
| Max. Negotiated Rate |
$96,058.56 |
| Rate for Payer: Aetna Managed Medicare |
$28,624.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80,111.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61,404.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58,338.49
|
| Rate for Payer: Anthem Medicare Advantage |
$28,624.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28,624.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28,624.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28,624.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64,761.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28,624.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70,211.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28,624.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28,624.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28,624.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28,624.61
|
| Rate for Payer: NAPHCARE Commercial |
$42,936.91
|
| Rate for Payer: Quartz Medicare Advantage |
$28,624.61
|
| Rate for Payer: The Alliance Commercial |
$96,058.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28,624.61
|
| Rate for Payer: United Healthcare PPO |
$54,660.47
|
| Rate for Payer: Wellcare Medicare |
$28,624.61
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$52,015.60
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$15,872.95 |
| Max. Negotiated Rate |
$52,015.60 |
| Rate for Payer: Aetna Managed Medicare |
$15,872.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43,780.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33,557.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31,881.52
|
| Rate for Payer: Anthem Medicare Advantage |
$15,872.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,872.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,872.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,872.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,391.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,872.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,907.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,872.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,872.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,872.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,872.95
|
| Rate for Payer: NAPHCARE Commercial |
$23,809.42
|
| Rate for Payer: Quartz Medicare Advantage |
$15,872.95
|
| Rate for Payer: The Alliance Commercial |
$52,015.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,872.95
|
| Rate for Payer: United Healthcare PPO |
$29,511.38
|
| Rate for Payer: Wellcare Medicare |
$15,872.95
|
|
|
LOWER EXTREMITY STUDY 9392526
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 93925 26
|
| Hospital Charge Code |
3015434
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.73 |
| Max. Negotiated Rate |
$241.07 |
| Rate for Payer: Aetna Commercial |
$241.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$36.16
|
| Rate for Payer: Anthem Medicare Advantage |
$36.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.16
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$241.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.16
|
| Rate for Payer: Health EOS Commercial |
$230.92
|
| Rate for Payer: HFN Commercial |
$241.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.16
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$54.24
|
| Rate for Payer: Preferred Network Access Commercial |
$241.07
|
| Rate for Payer: Quartz Beloit One Network |
$111.65
|
| Rate for Payer: Quartz Commercial |
$144.64
|
| Rate for Payer: Quartz Medicare Advantage |
$36.16
|
| Rate for Payer: The Alliance Commercial |
$90.40
|
| Rate for Payer: United Healthcare Medicaid |
$31.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.16
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$144.64
|
|
|
LOWER EXTREMITY VASCULAR PROCEDURES
|
Facility
|
IP
|
$15,344.54
|
|
|
Service Code
|
APR-DRG 1811
|
| Min. Negotiated Rate |
$13,629.98 |
| Max. Negotiated Rate |
$15,344.54 |
| Rate for Payer: Anthem Medicaid |
$14,693.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,693.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,693.25
|
| Rate for Payer: Dean Health Medicaid |
$14,693.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,629.98
|
| Rate for Payer: Managed Health Services Medicaid |
$15,344.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,693.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,693.25
|
| Rate for Payer: United Healthcare Medicaid |
$14,693.25
|
|
|
LOWER EXTREMITY VASCULAR PROCEDURES
|
Facility
|
IP
|
$21,131.63
|
|
|
Service Code
|
APR-DRG 1812
|
| Min. Negotiated Rate |
$18,770.43 |
| Max. Negotiated Rate |
$21,131.63 |
| Rate for Payer: Anthem Medicaid |
$20,234.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$20,234.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20,234.70
|
| Rate for Payer: Dean Health Medicaid |
$20,234.70
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,770.43
|
| Rate for Payer: Managed Health Services Medicaid |
$21,131.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,234.70
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20,234.70
|
| Rate for Payer: United Healthcare Medicaid |
$20,234.70
|
|
|
LOWER EXTREMITY VASCULAR PROCEDURES
|
Facility
|
IP
|
$41,035.69
|
|
|
Service Code
|
APR-DRG 1814
|
| Min. Negotiated Rate |
$36,450.46 |
| Max. Negotiated Rate |
$41,035.69 |
| Rate for Payer: Anthem Medicaid |
$39,293.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$39,293.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39,293.94
|
| Rate for Payer: Dean Health Medicaid |
$39,293.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36,450.46
|
| Rate for Payer: Managed Health Services Medicaid |
$41,035.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$39,293.94
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$39,293.94
|
| Rate for Payer: United Healthcare Medicaid |
$39,293.94
|
|
|
LOWER EXTREMITY VASCULAR PROCEDURES
|
Facility
|
IP
|
$28,233.96
|
|
|
Service Code
|
APR-DRG 1813
|
| Min. Negotiated Rate |
$25,079.16 |
| Max. Negotiated Rate |
$28,233.96 |
| Rate for Payer: Anthem Medicaid |
$27,035.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27,035.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27,035.57
|
| Rate for Payer: Dean Health Medicaid |
$27,035.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$25,079.16
|
| Rate for Payer: Managed Health Services Medicaid |
$28,233.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$27,035.57
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27,035.57
|
| Rate for Payer: United Healthcare Medicaid |
$27,035.57
|
|
|
Loxapine
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$340.86 |
| Rate for Payer: Aetna Commercial |
$340.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$308.57
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$340.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$179.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$326.51
|
| Rate for Payer: HFN Commercial |
$340.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$287.04
|
| Rate for Payer: Preferred Network Access Commercial |
$340.86
|
| Rate for Payer: Quartz Beloit One Network |
$157.87
|
| Rate for Payer: Quartz Commercial |
$204.52
|
| Rate for Payer: The Alliance Commercial |
$179.40
|
| Rate for Payer: WEA Trust Commercial |
$197.34
|
| Rate for Payer: WPS Commercial |
$265.75
|
|
|
Loxapine
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.46 |
| Max. Negotiated Rate |
$330.10 |
| Rate for Payer: Aetna Commercial |
$322.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$308.57
|
| Rate for Payer: Aetna Managed Medicare |
$100.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$233.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$179.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$172.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.16
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$330.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.79
|
| Rate for Payer: Health EOS Commercial |
$319.33
|
| Rate for Payer: HFN Commercial |
$330.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$269.10
|
| Rate for Payer: Multiplan Commercial |
$287.04
|
| Rate for Payer: NAPHCARE Commercial |
$215.28
|
| Rate for Payer: Preferred Network Access Commercial |
$330.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.81
|
| Rate for Payer: Quartz Commercial |
$233.22
|
| Rate for Payer: Quartz Medicare Advantage |
$215.28
|
| Rate for Payer: The Alliance Commercial |
$179.40
|
| Rate for Payer: United Healthcare PPO |
$269.10
|
| Rate for Payer: WEA Trust Commercial |
$197.34
|
| Rate for Payer: WPS Commercial |
$265.75
|
|
|
Loxapine
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$175.81 |
| Max. Negotiated Rate |
$330.10 |
| Rate for Payer: Aetna Commercial |
$322.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$308.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.16
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$330.10
|
| Rate for Payer: Health EOS Commercial |
$319.33
|
| Rate for Payer: HFN Commercial |
$330.10
|
| Rate for Payer: Multiplan Commercial |
$287.04
|
| Rate for Payer: Preferred Network Access Commercial |
$330.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.81
|
| Rate for Payer: Quartz Commercial |
$215.28
|
| Rate for Payer: WEA Trust Commercial |
$197.34
|
| Rate for Payer: WPS Commercial |
$265.75
|
|
|
LPE Interpretation
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.20 |
| Max. Negotiated Rate |
$281.42 |
| Rate for Payer: Aetna Commercial |
$123.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$63.96
|
| Rate for Payer: Anthem Medicare Advantage |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.96
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$123.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$65.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.96
|
| Rate for Payer: Health EOS Commercial |
$118.30
|
| Rate for Payer: HFN Commercial |
$123.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$225.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$95.94
|
| Rate for Payer: Preferred Network Access Commercial |
$123.50
|
| Rate for Payer: Quartz Beloit One Network |
$57.20
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$63.96
|
| Rate for Payer: The Alliance Commercial |
$252.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$281.42
|
|
|
LPE Interpretation
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$255.84 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$63.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.17
|
| Rate for Payer: Anthem Medicare Advantage |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.96
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$63.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$63.96
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$63.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$95.94
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$63.96
|
| Rate for Payer: The Alliance Commercial |
$255.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.96
|
| Rate for Payer: United Healthcare PPO |
$97.50
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: Wellcare Medicare |
$63.96
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
LPE Interpretation
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT LT 249.689
|
Facility
|
OP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$751.88 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$751.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,745.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,342.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,288.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,502.72
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,013.96
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,611.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,745.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,611.17
|
| Rate for Payer: The Alliance Commercial |
$1,342.64
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT LT 249.689
|
Facility
|
IP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,315.79 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,611.17
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT RT 249.688
|
Facility
|
IP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,315.79 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,611.17
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT RT 249.688
|
Facility
|
OP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$751.88 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$751.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,745.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,342.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,288.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,502.72
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,013.96
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,611.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,745.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,611.17
|
| Rate for Payer: The Alliance Commercial |
$1,342.64
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 3 X 4HL RT 0.8 THICK TI 04.503.386
|
Facility
|
OP
|
$4,433.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,290.89 |
| Max. Negotiated Rate |
$4,241.49 |
| Rate for Payer: Aetna Commercial |
$4,149.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,964.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,290.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,996.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,305.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,212.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,443.47
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,241.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,580.01
|
| Rate for Payer: Health EOS Commercial |
$4,103.18
|
| Rate for Payer: HFN Commercial |
$4,241.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,457.74
|
| Rate for Payer: Multiplan Commercial |
$3,688.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,766.19
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,259.06
|
| Rate for Payer: Quartz Commercial |
$2,996.71
|
| Rate for Payer: Quartz Medicare Advantage |
$2,766.19
|
| Rate for Payer: The Alliance Commercial |
$2,305.16
|
| Rate for Payer: WEA Trust Commercial |
$2,535.68
|
| Rate for Payer: WPS Commercial |
$3,414.74
|
|
