|
ANKLE BRACE UNIVERSAL LIGHT
|
Facility
|
OP
|
$603.00
|
|
| Hospital Charge Code |
2971457
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$175.59 |
| Max. Negotiated Rate |
$576.95 |
| Rate for Payer: Aetna Commercial |
$564.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$539.32
|
| Rate for Payer: Aetna Managed Medicare |
$175.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$301.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$332.37
|
| Rate for Payer: Cash Price |
$180.90
|
| Rate for Payer: Cigna Commercial |
$576.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.95
|
| Rate for Payer: Health EOS Commercial |
$558.14
|
| Rate for Payer: HFN Commercial |
$576.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$470.34
|
| Rate for Payer: Multiplan Commercial |
$501.70
|
| Rate for Payer: NAPHCARE Commercial |
$376.27
|
| Rate for Payer: Preferred Network Access Commercial |
$576.95
|
| Rate for Payer: Quartz Beloit One Network |
$307.29
|
| Rate for Payer: Quartz Commercial |
$407.63
|
| Rate for Payer: Quartz Medicare Advantage |
$376.27
|
| Rate for Payer: The Alliance Commercial |
$313.56
|
| Rate for Payer: WEA Trust Commercial |
$344.92
|
| Rate for Payer: WPS Commercial |
$464.49
|
|
|
ANKLE, LIGAMENT RECONSTRUCTION
|
Facility
|
IP
|
$4,560.00
|
|
| Hospital Charge Code |
2960200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,323.78 |
| Max. Negotiated Rate |
$4,363.01 |
| Rate for Payer: Aetna Commercial |
$4,268.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,078.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,513.47
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,363.01
|
| Rate for Payer: Health EOS Commercial |
$4,220.74
|
| Rate for Payer: HFN Commercial |
$4,363.01
|
| Rate for Payer: Multiplan Commercial |
$3,793.92
|
| Rate for Payer: Preferred Network Access Commercial |
$4,363.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,323.78
|
| Rate for Payer: Quartz Commercial |
$2,845.44
|
| Rate for Payer: WEA Trust Commercial |
$2,608.32
|
| Rate for Payer: WPS Commercial |
$3,512.57
|
|
|
ANKLE, LIGAMENT RECONSTRUCTION
|
Facility
|
OP
|
$4,560.00
|
|
| Hospital Charge Code |
2960200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,327.87 |
| Max. Negotiated Rate |
$4,363.01 |
| Rate for Payer: Aetna Commercial |
$4,268.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,078.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,327.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,082.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,371.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,276.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,513.47
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,363.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,653.92
|
| Rate for Payer: Health EOS Commercial |
$4,220.74
|
| Rate for Payer: HFN Commercial |
$4,363.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,556.80
|
| Rate for Payer: Multiplan Commercial |
$3,793.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,845.44
|
| Rate for Payer: Preferred Network Access Commercial |
$4,363.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,323.78
|
| Rate for Payer: Quartz Commercial |
$3,082.56
|
| Rate for Payer: Quartz Medicare Advantage |
$2,845.44
|
| Rate for Payer: The Alliance Commercial |
$2,371.20
|
| Rate for Payer: WEA Trust Commercial |
$2,608.32
|
| Rate for Payer: WPS Commercial |
$3,512.57
|
|
|
ANKLE, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960415
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
ANKLE, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960415
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,125.03 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,602.08
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
ANNA-2 & 3
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.24 |
| Max. Negotiated Rate |
$341.85 |
| Rate for Payer: Aetna Commercial |
$341.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.46
|
| Rate for Payer: Aetna Managed Medicare |
$53.24
|
| Rate for Payer: Anthem Medicare Advantage |
$53.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.24
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$341.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$179.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.24
|
| Rate for Payer: Health EOS Commercial |
$327.45
|
| Rate for Payer: HFN Commercial |
$341.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.24
|
| Rate for Payer: Multiplan Commercial |
$287.87
|
| Rate for Payer: NAPHCARE Commercial |
$79.86
|
| Rate for Payer: Preferred Network Access Commercial |
$341.85
|
| Rate for Payer: Quartz Beloit One Network |
$158.33
|
| Rate for Payer: Quartz Commercial |
$205.11
|
| Rate for Payer: Quartz Medicare Advantage |
$53.24
|
| Rate for Payer: The Alliance Commercial |
$210.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.24
|
| Rate for Payer: WEA Trust Commercial |
$197.91
|
| Rate for Payer: WPS Commercial |
$234.25
|
|
|
ANNA-2 & 3
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.24 |
| Max. Negotiated Rate |
$331.05 |
| Rate for Payer: Aetna Commercial |
$323.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.46
|
| Rate for Payer: Aetna Managed Medicare |
$53.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$199.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.37
|
| Rate for Payer: Anthem Medicare Advantage |
$53.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.24
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$331.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.24
|
| Rate for Payer: Health EOS Commercial |
$320.26
|
| Rate for Payer: HFN Commercial |
$331.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.24
|
| Rate for Payer: Multiplan Commercial |
$287.87
|
| Rate for Payer: NAPHCARE Commercial |
$79.86
|
| Rate for Payer: Preferred Network Access Commercial |
$331.05
|
| Rate for Payer: Quartz Beloit One Network |
$176.32
|
| Rate for Payer: Quartz Commercial |
$233.90
|
| Rate for Payer: Quartz Medicare Advantage |
$53.24
|
| Rate for Payer: The Alliance Commercial |
$212.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.24
|
| Rate for Payer: United Healthcare PPO |
$269.88
|
| Rate for Payer: WEA Trust Commercial |
$197.91
|
| Rate for Payer: Wellcare Medicare |
$53.24
|
| Rate for Payer: WPS Commercial |
$266.52
|
|
|
ANNA-2 & 3
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.32 |
| Max. Negotiated Rate |
$331.05 |
| Rate for Payer: Aetna Commercial |
$323.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.72
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$331.05
|
| Rate for Payer: Health EOS Commercial |
$320.26
|
| Rate for Payer: HFN Commercial |
$331.05
|
| Rate for Payer: Multiplan Commercial |
$287.87
|
| Rate for Payer: Preferred Network Access Commercial |
$331.05
|
| Rate for Payer: Quartz Beloit One Network |
$176.32
|
| Rate for Payer: Quartz Commercial |
$215.90
|
| Rate for Payer: WEA Trust Commercial |
$197.91
|
| Rate for Payer: WPS Commercial |
$266.52
|
|
|
ANNA-2 and 3
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942980
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
ANNA-2 and 3
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942980
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$138.84
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
ANNA-2 and 3
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942980
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$175.86 |
| Rate for Payer: Aetna Commercial |
$175.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$175.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$175.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$175.86
|
| Rate for Payer: Quartz Beloit One Network |
$81.45
|
| Rate for Payer: Quartz Commercial |
$105.52
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
ANNA-3
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
ANNA-3
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna Commercial |
$80.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$80.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$76.66
|
| Rate for Payer: HFN Commercial |
$80.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$80.03
|
| Rate for Payer: Quartz Beloit One Network |
$37.07
|
| Rate for Payer: Quartz Commercial |
$48.02
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
ANNA-3
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$63.18
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
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 |
$8.02 |
| Max. Negotiated Rate |
$33.08 |
| Rate for Payer: Aetna Commercial |
$25.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Aetna Managed Medicare |
$8.02
|
| Rate for Payer: Anthem Medicare Advantage |
$8.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.02
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$25.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.02
|
| Rate for Payer: Health EOS Commercial |
$24.61
|
| Rate for Payer: HFN Commercial |
$25.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.02
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: NAPHCARE Commercial |
$12.03
|
| Rate for Payer: Preferred Network Access Commercial |
$25.69
|
| Rate for Payer: Quartz Beloit One Network |
$11.90
|
| Rate for Payer: Quartz Commercial |
$15.41
|
| Rate for Payer: Quartz Medicare Advantage |
$8.02
|
| Rate for Payer: The Alliance Commercial |
$22.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.02
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$14.03
|
|
|
Annual Wellness Visit Initial
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
1122841
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.60 |
| Max. Negotiated Rate |
$592.17 |
| Rate for Payer: Aetna Commercial |
$370.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$173.67
|
| Rate for Payer: Anthem Medicare Advantage |
$173.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$173.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$173.67
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$370.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$173.67
|
| Rate for Payer: Health EOS Commercial |
$354.90
|
| Rate for Payer: HFN Commercial |
$370.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$592.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$592.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$173.67
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$260.50
|
| Rate for Payer: Preferred Network Access Commercial |
$370.50
|
| Rate for Payer: Quartz Beloit One Network |
$171.60
|
| Rate for Payer: Quartz Commercial |
$222.30
|
| Rate for Payer: Quartz Medicare Advantage |
$173.67
|
| Rate for Payer: The Alliance Commercial |
$477.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$173.67
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$303.92
|
|
|
Annual Wellness Visit Subsequent
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
1122842
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.52 |
| Max. Negotiated Rate |
$465.66 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$136.97
|
| Rate for Payer: Anthem Medicare Advantage |
$136.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$136.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$136.97
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.97
|
| Rate for Payer: Health EOS Commercial |
$189.28
|
| Rate for Payer: HFN Commercial |
$197.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$465.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$465.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$136.97
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$205.45
|
| Rate for Payer: Preferred Network Access Commercial |
$197.60
|
| Rate for Payer: Quartz Beloit One Network |
$91.52
|
| Rate for Payer: Quartz Commercial |
$118.56
|
| Rate for Payer: Quartz Medicare Advantage |
$136.97
|
| Rate for Payer: The Alliance Commercial |
$376.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$136.97
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$239.69
|
|
|
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 |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$3,553.22 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Aetna Managed Medicare |
$3,553.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,248.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,345.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,091.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,101.56
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,517.56
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,614.05
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$8,248.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,614.05
|
| Rate for Payer: The Alliance Commercial |
$6,345.04
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
|
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 |
$6,218.14 |
| Max. Negotiated Rate |
$11,674.87 |
| Rate for Payer: Aetna Commercial |
$11,421.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,913.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,725.74
|
| Rate for Payer: Cash Price |
$3,660.60
|
| Rate for Payer: Cigna Commercial |
$11,674.87
|
| Rate for Payer: Health EOS Commercial |
$11,294.17
|
| Rate for Payer: HFN Commercial |
$11,674.87
|
| Rate for Payer: Multiplan Commercial |
$10,152.06
|
| Rate for Payer: Preferred Network Access Commercial |
$11,674.87
|
| Rate for Payer: Quartz Beloit One Network |
$6,218.14
|
| Rate for Payer: Quartz Commercial |
$7,614.05
|
| Rate for Payer: WEA Trust Commercial |
$6,979.54
|
| Rate for Payer: WPS Commercial |
$9,399.20
|
|
