|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$33,824.00
|
|
|
Service Code
|
MSDRG 735
|
| Min. Negotiated Rate |
$12,166.93 |
| Max. Negotiated Rate |
$33,824.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,166.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,434.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,262.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,250.28
|
| Rate for Payer: Anthem Medicare Advantage |
$12,166.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,166.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,166.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,166.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,369.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,166.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,573.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,166.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,166.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,166.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,166.93
|
| Rate for Payer: NAPHCARE Commercial |
$18,250.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12,166.93
|
| Rate for Payer: The Alliance Commercial |
$33,824.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,166.93
|
| Rate for Payer: United Healthcare PPO |
$19,131.10
|
| Rate for Payer: Wellcare Medicare |
$12,166.93
|
|
|
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$12,360.48
|
|
|
Service Code
|
CPT 57410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$12,360.48 |
| Rate for Payer: Aetna Managed Medicare |
$3,090.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,090.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,090.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,090.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,495.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,090.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,090.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,090.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,090.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,635.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.12
|
| Rate for Payer: The Alliance Commercial |
$12,360.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,090.12
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,090.12
|
|
|
PELVIC EXAM UNDER ANESTHESIA
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
4075914
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
PELVIC EXAM UNDER ANESTHESIA
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
4075914
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
PELVIC EXPLORATION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960311
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
PELVIC EXPLORATION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960311
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
PELVIC & PARA AORTIC LYMPH NODE DISSECTION
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960312
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PELVIC & PARA AORTIC LYMPH NODE DISSECTION
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960312
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PELVIC PLATE L STRAIGHT 122.5MM X 8HL 425708
|
Facility
|
OP
|
$4,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6198986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,181.04 |
| Max. Negotiated Rate |
$16,872.00 |
| Rate for Payer: Aetna Commercial |
$3,796.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,627.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,181.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,741.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,109.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,024.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,235.54
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cigna Commercial |
$3,880.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,360.39
|
| Rate for Payer: Health EOS Commercial |
$3,754.02
|
| Rate for Payer: HFN Commercial |
$3,880.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,163.50
|
| Rate for Payer: Multiplan Commercial |
$3,374.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,530.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,880.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,066.82
|
| Rate for Payer: Quartz Commercial |
$2,741.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,530.80
|
| Rate for Payer: The Alliance Commercial |
$16,872.00
|
| Rate for Payer: WEA Trust Commercial |
$2,319.90
|
| Rate for Payer: WPS Commercial |
$3,124.27
|
|
|
PELVIC PLATE L STRAIGHT 122.5MM X 8HL 425708
|
Facility
|
IP
|
$4,218.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6198986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,066.82 |
| Max. Negotiated Rate |
$3,880.56 |
| Rate for Payer: Aetna Commercial |
$3,796.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,627.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,235.54
|
| Rate for Payer: Cash Price |
$1,265.40
|
| Rate for Payer: Cigna Commercial |
$3,880.56
|
| Rate for Payer: Health EOS Commercial |
$3,754.02
|
| Rate for Payer: HFN Commercial |
$3,880.56
|
| Rate for Payer: Multiplan Commercial |
$3,374.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,530.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,880.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,066.82
|
| Rate for Payer: Quartz Commercial |
$2,530.80
|
| Rate for Payer: WEA Trust Commercial |
$2,319.90
|
| Rate for Payer: WPS Commercial |
$3,124.27
|
|
|
PENCIL HAND SWITCHING DISP E2515H
|
Facility
|
IP
|
$111.00
|
|
| Hospital Charge Code |
2963133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$102.12 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$66.60
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
PENCIL HAND SWITCHING DISP E2515H
|
Facility
|
OP
|
$111.00
|
|
| Hospital Charge Code |
2963133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$31.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.25
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$72.15
|
| Rate for Payer: Quartz Medicare Advantage |
$66.60
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
PENCIL SMOKE EVAC 0703-046-000
|
Facility
|
OP
|
$667.00
|
|
| Hospital Charge Code |
4520032
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.76 |
| Max. Negotiated Rate |
$2,668.00 |
| Rate for Payer: Aetna Commercial |
$600.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$573.62
|
| Rate for Payer: Aetna Managed Medicare |
$186.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$433.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$333.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.51
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$613.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.25
|
| Rate for Payer: Health EOS Commercial |
$593.63
|
| Rate for Payer: HFN Commercial |
$613.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$500.25
|
| Rate for Payer: Multiplan Commercial |
$533.60
|
| Rate for Payer: NAPHCARE Commercial |
$400.20
|
| Rate for Payer: Preferred Network Access Commercial |
$613.64
|
| Rate for Payer: Quartz Beloit One Network |
$326.83
|
| Rate for Payer: Quartz Commercial |
$433.55
|
| Rate for Payer: Quartz Medicare Advantage |
$400.20
|
| Rate for Payer: The Alliance Commercial |
$2,668.00
|
| Rate for Payer: WEA Trust Commercial |
$366.85
|
| Rate for Payer: WPS Commercial |
$494.05
|
|
|
PENCIL SMOKE EVAC 0703-046-000
|
Facility
|
IP
|
$667.00
|
|
| Hospital Charge Code |
4520032
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$326.83 |
| Max. Negotiated Rate |
$613.64 |
| Rate for Payer: Aetna Commercial |
$600.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$573.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.51
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$613.64
|
| Rate for Payer: Health EOS Commercial |
$593.63
|
| Rate for Payer: HFN Commercial |
$613.64
|
| Rate for Payer: Multiplan Commercial |
$533.60
|
| Rate for Payer: NAPHCARE Commercial |
$400.20
|
| Rate for Payer: Preferred Network Access Commercial |
$613.64
|
| Rate for Payer: Quartz Beloit One Network |
$326.83
|
| Rate for Payer: Quartz Commercial |
$400.20
|
| Rate for Payer: WEA Trust Commercial |
$366.85
|
| Rate for Payer: WPS Commercial |
$494.05
|
|
|
PEN ELECTRODE ISOLATOR 20MM MLP1
|
Facility
|
IP
|
$17,682.00
|
|
| Hospital Charge Code |
2964753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,664.18 |
| Max. Negotiated Rate |
$16,267.44 |
| Rate for Payer: Aetna Commercial |
$15,913.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,206.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,371.46
|
| Rate for Payer: Cash Price |
$5,304.60
|
| Rate for Payer: Cigna Commercial |
$16,267.44
|
| Rate for Payer: Health EOS Commercial |
$15,736.98
|
| Rate for Payer: HFN Commercial |
$16,267.44
|
| Rate for Payer: Multiplan Commercial |
$14,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$10,609.20
|
| Rate for Payer: Preferred Network Access Commercial |
$16,267.44
|
| Rate for Payer: Quartz Beloit One Network |
$8,664.18
|
| Rate for Payer: Quartz Commercial |
$10,609.20
|
| Rate for Payer: WEA Trust Commercial |
$9,725.10
|
| Rate for Payer: WPS Commercial |
$13,097.06
|
|
|
PEN ELECTRODE ISOLATOR 20MM MLP1
|
Facility
|
OP
|
$17,682.00
|
|
| Hospital Charge Code |
2964753
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,950.96 |
| Max. Negotiated Rate |
$70,728.00 |
| Rate for Payer: Aetna Commercial |
$15,913.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,206.52
|
| Rate for Payer: Aetna Managed Medicare |
$4,950.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,493.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,841.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,487.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,371.46
|
| Rate for Payer: Cash Price |
$5,304.60
|
| Rate for Payer: Cigna Commercial |
$16,267.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,894.85
|
| Rate for Payer: Health EOS Commercial |
$15,736.98
|
| Rate for Payer: HFN Commercial |
$16,267.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,261.50
|
| Rate for Payer: Multiplan Commercial |
$14,145.60
|
| Rate for Payer: NAPHCARE Commercial |
$10,609.20
|
| Rate for Payer: Preferred Network Access Commercial |
$16,267.44
|
| Rate for Payer: Quartz Beloit One Network |
$8,664.18
|
| Rate for Payer: Quartz Commercial |
$11,493.30
|
| Rate for Payer: Quartz Medicare Advantage |
$10,609.20
|
| Rate for Payer: The Alliance Commercial |
$70,728.00
|
| Rate for Payer: WEA Trust Commercial |
$9,725.10
|
| Rate for Payer: WPS Commercial |
$13,097.06
|
|
|
Penicillin G Benzathine 100,000=1 uniti Charge
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
2983535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.00
|
| Rate for Payer: Health EOS Commercial |
$58.24
|
| Rate for Payer: HFN Commercial |
$60.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.24
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: Preferred Network Access Commercial |
$60.80
|
| Rate for Payer: Quartz Beloit One Network |
$28.16
|
| Rate for Payer: Quartz Commercial |
$36.48
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: United Healthcare Medicaid |
$21.73
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Penicillin G Benzathine 100,000=1 uniti Charge
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
2983535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$86.92 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Aetna Managed Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.72
|
| Rate for Payer: Anthem Medicare Advantage |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.73
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.73
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.60
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$41.60
|
| Rate for Payer: Quartz Medicare Advantage |
$21.73
|
| Rate for Payer: The Alliance Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.73
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: Wellcare Medicare |
$21.73
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Penicillin G Benzathine 100,000=1 uniti Charge
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
2983535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.36 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$58.88
|
| Rate for Payer: Health EOS Commercial |
$56.96
|
| Rate for Payer: HFN Commercial |
$58.88
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: NAPHCARE Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$58.88
|
| Rate for Payer: Quartz Beloit One Network |
$31.36
|
| Rate for Payer: Quartz Commercial |
$38.40
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Penicillin G Benzathine JW Waste Chg per 100,000 u
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS J0561 JW
|
| Hospital Charge Code |
5266701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$86.92 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Anthem Medicare Advantage |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.73
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.73
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$32.60
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$21.73
|
| Rate for Payer: The Alliance Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.73
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: Wellcare Medicare |
$21.73
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Penicillin G Benzathine JW Waste Chg per 100,000 u
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS J0561 JW
|
| Hospital Charge Code |
5266701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.00
|
| Rate for Payer: Health EOS Commercial |
$48.23
|
| Rate for Payer: HFN Commercial |
$50.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.24
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: Preferred Network Access Commercial |
$50.35
|
| Rate for Payer: Quartz Beloit One Network |
$23.32
|
| Rate for Payer: Quartz Commercial |
$30.21
|
| Rate for Payer: The Alliance Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicaid |
$22.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Penicillin G Benzathine JW Waste Chg per 100,000 u
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS J0561 JW
|
| Hospital Charge Code |
5266701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
Penicillin G / Procaine 1,200,000 Charge
|
Professional
|
Both
|
$521.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
2983474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$494.95 |
| Rate for Payer: Aetna Commercial |
$494.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$448.06
|
| Rate for Payer: Cash Price |
$156.30
|
| Rate for Payer: Cash Price |
$156.30
|
| Rate for Payer: Cigna Commercial |
$494.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.37
|
| Rate for Payer: Health EOS Commercial |
$474.11
|
| Rate for Payer: HFN Commercial |
$494.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.61
|
| Rate for Payer: Multiplan Commercial |
$416.80
|
| Rate for Payer: Preferred Network Access Commercial |
$494.95
|
| Rate for Payer: Quartz Beloit One Network |
$229.24
|
| Rate for Payer: Quartz Commercial |
$296.97
|
| Rate for Payer: The Alliance Commercial |
$260.50
|
| Rate for Payer: United Healthcare Medicaid |
$17.37
|
| Rate for Payer: WEA Trust Commercial |
$286.55
|
| Rate for Payer: WPS Commercial |
$43.42
|
|
|
Penicillin G / Procaine 1,200,000 Charge
|
Facility
|
OP
|
$521.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
2983474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$479.32 |
| Rate for Payer: Aetna Commercial |
$468.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$448.06
|
| Rate for Payer: Aetna Managed Medicare |
$17.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$338.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$260.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$250.08
|
| Rate for Payer: Anthem Medicare Advantage |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$276.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.58
|
| Rate for Payer: Cash Price |
$156.30
|
| Rate for Payer: Cash Price |
$156.30
|
| Rate for Payer: Cigna Commercial |
$479.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.58
|
| Rate for Payer: Health EOS Commercial |
$463.69
|
| Rate for Payer: HFN Commercial |
$479.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.58
|
| Rate for Payer: Multiplan Commercial |
$416.80
|
| Rate for Payer: NAPHCARE Commercial |
$26.37
|
| Rate for Payer: Preferred Network Access Commercial |
$479.32
|
| Rate for Payer: Quartz Beloit One Network |
$255.29
|
| Rate for Payer: Quartz Commercial |
$338.65
|
| Rate for Payer: Quartz Medicare Advantage |
$17.58
|
| Rate for Payer: The Alliance Commercial |
$70.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.58
|
| Rate for Payer: WEA Trust Commercial |
$286.55
|
| Rate for Payer: Wellcare Medicare |
$17.58
|
| Rate for Payer: WPS Commercial |
$43.42
|
|
|
Penicillin G / Procaine 1,200,000 Charge
|
Facility
|
IP
|
$521.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
2983474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$255.29 |
| Max. Negotiated Rate |
$479.32 |
| Rate for Payer: Aetna Commercial |
$468.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$448.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$276.13
|
| Rate for Payer: Cash Price |
$156.30
|
| Rate for Payer: Cigna Commercial |
$479.32
|
| Rate for Payer: Health EOS Commercial |
$463.69
|
| Rate for Payer: HFN Commercial |
$479.32
|
| Rate for Payer: Multiplan Commercial |
$416.80
|
| Rate for Payer: NAPHCARE Commercial |
$312.60
|
| Rate for Payer: Preferred Network Access Commercial |
$479.32
|
| Rate for Payer: Quartz Beloit One Network |
$255.29
|
| Rate for Payer: Quartz Commercial |
$312.60
|
| Rate for Payer: WEA Trust Commercial |
$286.55
|
| Rate for Payer: WPS Commercial |
$385.90
|
|
