|
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
|
Facility
|
OP
|
$30,545.47
|
|
|
Service Code
|
CPT 22513
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,636.37 |
| Max. Negotiated Rate |
$30,545.47 |
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
|
|
Percutaneous Vertebroplsty Lumbosacral w/guidance 22511
|
Professional
|
Both
|
$3,961.00
|
|
|
Service Code
|
CPT 22511
|
| Hospital Charge Code |
5232607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$346.34 |
| Max. Negotiated Rate |
$3,913.47 |
| Rate for Payer: Aetna Commercial |
$3,913.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,542.72
|
| Rate for Payer: Aetna Managed Medicare |
$346.34
|
| Rate for Payer: Anthem Medicare Advantage |
$346.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$346.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$346.34
|
| Rate for Payer: Cash Price |
$1,188.30
|
| Rate for Payer: Cash Price |
$1,188.30
|
| Rate for Payer: Cash Price |
$1,188.30
|
| Rate for Payer: Cigna Commercial |
$3,913.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,383.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.34
|
| Rate for Payer: Health EOS Commercial |
$3,748.69
|
| Rate for Payer: HFN Commercial |
$3,913.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,405.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,405.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$346.34
|
| Rate for Payer: Multiplan Commercial |
$3,295.55
|
| Rate for Payer: NAPHCARE Commercial |
$519.51
|
| Rate for Payer: Preferred Network Access Commercial |
$3,913.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,812.55
|
| Rate for Payer: Quartz Commercial |
$2,348.08
|
| Rate for Payer: Quartz Medicare Advantage |
$346.34
|
| Rate for Payer: The Alliance Commercial |
$1,471.95
|
| Rate for Payer: United Healthcare Medicaid |
$1,383.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$346.34
|
| Rate for Payer: WEA Trust Commercial |
$2,265.69
|
| Rate for Payer: WPS Commercial |
$1,558.53
|
|
|
Percutans Test Sequtl/Incremtl,W/Drgs,Bio Or Venms,Immed React
|
Professional
|
Both
|
$23.00
|
|
| Hospital Charge Code |
1188808
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.52 |
| Max. Negotiated Rate |
$22.72 |
| Rate for Payer: Aetna Commercial |
$22.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.35
|
| Rate for Payer: Health EOS Commercial |
$21.77
|
| Rate for Payer: HFN Commercial |
$22.72
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: Preferred Network Access Commercial |
$22.72
|
| Rate for Payer: Quartz Beloit One Network |
$10.52
|
| Rate for Payer: Quartz Commercial |
$13.63
|
| Rate for Payer: The Alliance Commercial |
$11.96
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
Pericardial DRG 6YR+ W/O CGen Car Anomaly
|
Facility
|
OP
|
$3,065.00
|
|
|
Service Code
|
CPT 33017
|
| Hospital Charge Code |
6172827
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$785.57 |
| Max. Negotiated Rate |
$4,947.89 |
| Rate for Payer: Aetna Commercial |
$2,868.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,741.34
|
| Rate for Payer: Aetna Managed Medicare |
$892.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,071.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,593.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,530.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,689.43
|
| Rate for Payer: Cash Price |
$919.50
|
| Rate for Payer: Cash Price |
$919.50
|
| Rate for Payer: Cigna Commercial |
$2,932.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Health EOS Commercial |
$2,836.96
|
| Rate for Payer: HFN Commercial |
$2,932.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,390.70
|
| Rate for Payer: Multiplan Commercial |
$2,550.08
|
| Rate for Payer: NAPHCARE Commercial |
$1,912.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,932.59
|
| Rate for Payer: Quartz Beloit One Network |
$1,561.92
|
| Rate for Payer: Quartz Commercial |
$2,071.94
|
| Rate for Payer: Quartz Medicare Advantage |
$1,912.56
|
| Rate for Payer: The Alliance Commercial |
$785.57
|
| Rate for Payer: WEA Trust Commercial |
$1,753.18
|
| Rate for Payer: WPS Commercial |
$2,360.97
|
|
|
Pericardial DRG 6YR+ W/O CGen Car Anomaly
|
Facility
|
IP
|
$3,065.00
|
|
|
Service Code
|
CPT 33017
|
| Hospital Charge Code |
6172827
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,561.92 |
| Max. Negotiated Rate |
$2,932.59 |
| Rate for Payer: Aetna Commercial |
$2,868.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,741.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,689.43
|
| Rate for Payer: Cash Price |
$919.50
|
| Rate for Payer: Cigna Commercial |
$2,932.59
|
| Rate for Payer: Health EOS Commercial |
$2,836.96
|
| Rate for Payer: HFN Commercial |
$2,932.59
|
| Rate for Payer: Multiplan Commercial |
$2,550.08
|
| Rate for Payer: Preferred Network Access Commercial |
$2,932.59
|
| Rate for Payer: Quartz Beloit One Network |
$1,561.92
|
| Rate for Payer: Quartz Commercial |
$1,912.56
|
| Rate for Payer: WEA Trust Commercial |
$1,753.18
|
| Rate for Payer: WPS Commercial |
$2,360.97
|
|
|
PERICARDIAL WINDOW
|
Facility
|
IP
|
$4,238.00
|
|
| Hospital Charge Code |
4494602
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,159.68 |
| Max. Negotiated Rate |
$4,054.92 |
| Rate for Payer: Aetna Commercial |
$3,966.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,790.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,335.99
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$4,054.92
|
| Rate for Payer: Health EOS Commercial |
$3,922.69
|
| Rate for Payer: HFN Commercial |
$4,054.92
|
| Rate for Payer: Multiplan Commercial |
$3,526.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,054.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,159.68
|
| Rate for Payer: Quartz Commercial |
$2,644.51
|
| Rate for Payer: WEA Trust Commercial |
$2,424.14
|
| Rate for Payer: WPS Commercial |
$3,264.53
|
|
|
PERICARDIAL WINDOW
|
Facility
|
OP
|
$4,238.00
|
|
| Hospital Charge Code |
4494602
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,234.11 |
| Max. Negotiated Rate |
$4,054.92 |
| Rate for Payer: Aetna Commercial |
$3,966.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,790.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,234.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,864.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,203.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,115.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,335.99
|
| Rate for Payer: Cash Price |
$1,271.40
|
| Rate for Payer: Cigna Commercial |
$4,054.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,466.52
|
| Rate for Payer: Health EOS Commercial |
$3,922.69
|
| Rate for Payer: HFN Commercial |
$4,054.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,305.64
|
| Rate for Payer: Multiplan Commercial |
$3,526.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,644.51
|
| Rate for Payer: Preferred Network Access Commercial |
$4,054.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,159.68
|
| Rate for Payer: Quartz Commercial |
$2,864.89
|
| Rate for Payer: Quartz Medicare Advantage |
$2,644.51
|
| Rate for Payer: The Alliance Commercial |
$2,203.76
|
| Rate for Payer: WEA Trust Commercial |
$2,424.14
|
| Rate for Payer: WPS Commercial |
$3,264.53
|
|
|
PERICARDIECTOMY
|
Facility
|
IP
|
$15,505.00
|
|
| Hospital Charge Code |
2960313
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,901.35 |
| Max. Negotiated Rate |
$14,835.18 |
| Rate for Payer: Aetna Commercial |
$14,512.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,867.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,546.36
|
| Rate for Payer: Cash Price |
$4,651.50
|
| Rate for Payer: Cigna Commercial |
$14,835.18
|
| Rate for Payer: Health EOS Commercial |
$14,351.43
|
| Rate for Payer: HFN Commercial |
$14,835.18
|
| Rate for Payer: Multiplan Commercial |
$12,900.16
|
| Rate for Payer: Preferred Network Access Commercial |
$14,835.18
|
| Rate for Payer: Quartz Beloit One Network |
$7,901.35
|
| Rate for Payer: Quartz Commercial |
$9,675.12
|
| Rate for Payer: WEA Trust Commercial |
$8,868.86
|
| Rate for Payer: WPS Commercial |
$11,943.50
|
|
|
PERICARDIECTOMY
|
Facility
|
OP
|
$15,505.00
|
|
| Hospital Charge Code |
2960313
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,515.06 |
| Max. Negotiated Rate |
$14,835.18 |
| Rate for Payer: Aetna Commercial |
$14,512.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,867.67
|
| Rate for Payer: Aetna Managed Medicare |
$4,515.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,481.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,062.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,740.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,546.36
|
| Rate for Payer: Cash Price |
$4,651.50
|
| Rate for Payer: Cigna Commercial |
$14,835.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,023.91
|
| Rate for Payer: Health EOS Commercial |
$14,351.43
|
| Rate for Payer: HFN Commercial |
$14,835.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,093.90
|
| Rate for Payer: Multiplan Commercial |
$12,900.16
|
| Rate for Payer: NAPHCARE Commercial |
$9,675.12
|
| Rate for Payer: Preferred Network Access Commercial |
$14,835.18
|
| Rate for Payer: Quartz Beloit One Network |
$7,901.35
|
| Rate for Payer: Quartz Commercial |
$10,481.38
|
| Rate for Payer: Quartz Medicare Advantage |
$9,675.12
|
| Rate for Payer: The Alliance Commercial |
$8,062.60
|
| Rate for Payer: WEA Trust Commercial |
$8,868.86
|
| Rate for Payer: WPS Commercial |
$11,943.50
|
|
|
Pericardiocentesis F/U
|
Facility
|
OP
|
$517.00
|
|
| Hospital Charge Code |
4125712
|
| Min. Negotiated Rate |
$150.55 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Aetna Managed Medicare |
$150.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$268.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$258.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.89
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.26
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: NAPHCARE Commercial |
$322.61
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$349.49
|
| Rate for Payer: Quartz Medicare Advantage |
$322.61
|
| Rate for Payer: The Alliance Commercial |
$268.84
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
Pericardiocentesis F/U
|
Facility
|
IP
|
$517.00
|
|
| Hospital Charge Code |
4125712
|
| Min. Negotiated Rate |
$263.46 |
| Max. Negotiated Rate |
$494.67 |
| Rate for Payer: Aetna Commercial |
$483.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$462.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$284.97
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$494.67
|
| Rate for Payer: Health EOS Commercial |
$478.54
|
| Rate for Payer: HFN Commercial |
$494.67
|
| Rate for Payer: Multiplan Commercial |
$430.14
|
| Rate for Payer: Preferred Network Access Commercial |
$494.67
|
| Rate for Payer: Quartz Beloit One Network |
$263.46
|
| Rate for Payer: Quartz Commercial |
$322.61
|
| Rate for Payer: WEA Trust Commercial |
$295.72
|
| Rate for Payer: WPS Commercial |
$398.25
|
|
|
Pericardiocentesis Including Imaging Guidance
|
Facility
|
IP
|
$2,870.00
|
|
|
Service Code
|
CPT 33016
|
| Hospital Charge Code |
5565259
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,462.55 |
| Max. Negotiated Rate |
$2,746.02 |
| Rate for Payer: Aetna Commercial |
$2,686.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,566.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,581.94
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$2,746.02
|
| Rate for Payer: Health EOS Commercial |
$2,656.47
|
| Rate for Payer: HFN Commercial |
$2,746.02
|
| Rate for Payer: Multiplan Commercial |
$2,387.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,746.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,462.55
|
| Rate for Payer: Quartz Commercial |
$1,790.88
|
| Rate for Payer: WEA Trust Commercial |
$1,641.64
|
| Rate for Payer: WPS Commercial |
$2,210.76
|
|
|
Pericardiocentesis Including Imaging Guidance
|
Facility
|
OP
|
$2,870.00
|
|
|
Service Code
|
CPT 33016
|
| Hospital Charge Code |
5565259
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,432.70 |
| Max. Negotiated Rate |
$6,626.51 |
| Rate for Payer: Aetna Commercial |
$2,686.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,566.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,656.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,940.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,492.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,432.70
|
| Rate for Payer: Anthem Medicare Advantage |
$1,656.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,581.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,656.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,656.63
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cigna Commercial |
$2,746.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,656.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,656.63
|
| Rate for Payer: Health EOS Commercial |
$2,656.47
|
| Rate for Payer: HFN Commercial |
$2,746.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,162.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,656.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,656.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,656.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,656.63
|
| Rate for Payer: Multiplan Commercial |
$2,387.84
|
| Rate for Payer: NAPHCARE Commercial |
$2,484.94
|
| Rate for Payer: Preferred Network Access Commercial |
$2,746.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,462.55
|
| Rate for Payer: Quartz Commercial |
$1,940.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.63
|
| Rate for Payer: The Alliance Commercial |
$6,626.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,656.63
|
| Rate for Payer: WEA Trust Commercial |
$1,641.64
|
| Rate for Payer: Wellcare Medicare |
$1,656.63
|
| Rate for Payer: WPS Commercial |
$2,210.76
|
|
|
Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
|
Facility
|
OP
|
$16,482.25
|
|
|
Service Code
|
CPT 19371
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,120.56 |
| Max. Negotiated Rate |
$16,482.25 |
| Rate for Payer: Aetna Managed Medicare |
$4,120.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$4,120.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,120.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,120.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,120.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,120.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,328.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,120.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,120.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,120.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,120.56
|
| Rate for Payer: NAPHCARE Commercial |
$6,180.84
|
| Rate for Payer: Quartz Medicare Advantage |
$4,120.56
|
| Rate for Payer: The Alliance Commercial |
$16,482.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,120.56
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$4,120.56
|
|
|
Periodic Comprehensive Preventive Medicine 12-17 Years Established
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
CPT 99394
|
| Hospital Charge Code |
1122830
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$79.51 |
| Max. Negotiated Rate |
$302.72 |
| Rate for Payer: Aetna Commercial |
$267.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$242.38
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$267.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.10
|
| Rate for Payer: Health EOS Commercial |
$256.47
|
| Rate for Payer: HFN Commercial |
$267.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$302.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$302.72
|
| Rate for Payer: Multiplan Commercial |
$225.47
|
| Rate for Payer: Preferred Network Access Commercial |
$267.75
|
| Rate for Payer: Quartz Beloit One Network |
$124.01
|
| Rate for Payer: Quartz Commercial |
$160.65
|
| Rate for Payer: The Alliance Commercial |
$140.92
|
| Rate for Payer: United Healthcare Medicaid |
$79.51
|
| Rate for Payer: WEA Trust Commercial |
$155.01
|
| Rate for Payer: WPS Commercial |
$208.75
|
|
|
Periodic Comprehensive Preventive Medicine 1-4 Years Established
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 99392
|
| Hospital Charge Code |
1122828
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.94 |
| Max. Negotiated Rate |
$267.08 |
| Rate for Payer: Aetna Commercial |
$204.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$204.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.17
|
| Rate for Payer: Health EOS Commercial |
$195.90
|
| Rate for Payer: HFN Commercial |
$204.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$267.08
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$204.52
|
| Rate for Payer: Quartz Beloit One Network |
$94.72
|
| Rate for Payer: Quartz Commercial |
$122.71
|
| Rate for Payer: The Alliance Commercial |
$107.64
|
| Rate for Payer: United Healthcare Medicaid |
$72.94
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
Periodic Comprehensive Preventive Medicine 18-39 Years Established
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
CPT 99395
|
| Hospital Charge Code |
1122831
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.29 |
| Max. Negotiated Rate |
$311.54 |
| Rate for Payer: Aetna Commercial |
$276.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.43
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$276.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.72
|
| Rate for Payer: Health EOS Commercial |
$264.99
|
| Rate for Payer: HFN Commercial |
$276.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.54
|
| Rate for Payer: Multiplan Commercial |
$232.96
|
| Rate for Payer: Preferred Network Access Commercial |
$276.64
|
| Rate for Payer: Quartz Beloit One Network |
$128.13
|
| Rate for Payer: Quartz Commercial |
$165.98
|
| Rate for Payer: The Alliance Commercial |
$145.60
|
| Rate for Payer: United Healthcare Medicaid |
$81.29
|
| Rate for Payer: WEA Trust Commercial |
$160.16
|
| Rate for Payer: WPS Commercial |
$215.68
|
|
|
Periodic Comprehensive Preventive Medicine < 1 Year Established
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 99391
|
| Hospital Charge Code |
1122827
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$243.62 |
| Rate for Payer: Aetna Commercial |
$184.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$184.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$68.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.69
|
| Rate for Payer: Health EOS Commercial |
$176.98
|
| Rate for Payer: HFN Commercial |
$184.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$243.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$243.62
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.76
|
| Rate for Payer: Quartz Beloit One Network |
$85.57
|
| Rate for Payer: Quartz Commercial |
$110.85
|
| Rate for Payer: The Alliance Commercial |
$97.24
|
| Rate for Payer: United Healthcare Medicaid |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Periodic Comprehensive Preventive Medicine 40-64 Years Established
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
CPT 99396
|
| Hospital Charge Code |
1122832
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.39 |
| Max. Negotiated Rate |
$338.37 |
| Rate for Payer: Aetna Commercial |
$301.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$272.79
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$301.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$86.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.32
|
| Rate for Payer: Health EOS Commercial |
$288.65
|
| Rate for Payer: HFN Commercial |
$301.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$338.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$338.37
|
| Rate for Payer: Multiplan Commercial |
$253.76
|
| Rate for Payer: Preferred Network Access Commercial |
$301.34
|
| Rate for Payer: Quartz Beloit One Network |
$139.57
|
| Rate for Payer: Quartz Commercial |
$180.80
|
| Rate for Payer: The Alliance Commercial |
$158.60
|
| Rate for Payer: United Healthcare Medicaid |
$86.39
|
| Rate for Payer: WEA Trust Commercial |
$174.46
|
| Rate for Payer: WPS Commercial |
$234.94
|
|
|
Periodic Comprehensive Preventive Medicine 5-11 Years Established
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 99393
|
| Hospital Charge Code |
1122829
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.70 |
| Max. Negotiated Rate |
$267.08 |
| Rate for Payer: Aetna Commercial |
$237.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.66
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$237.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.76
|
| Rate for Payer: Health EOS Commercial |
$227.14
|
| Rate for Payer: HFN Commercial |
$237.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$267.08
|
| Rate for Payer: Multiplan Commercial |
$199.68
|
| Rate for Payer: Preferred Network Access Commercial |
$237.12
|
| Rate for Payer: Quartz Beloit One Network |
$109.82
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: The Alliance Commercial |
$124.80
|
| Rate for Payer: United Healthcare Medicaid |
$72.70
|
| Rate for Payer: WEA Trust Commercial |
$137.28
|
| Rate for Payer: WPS Commercial |
$184.87
|
|
|
Periodic Comprehensive Preventive Medicine 65 Years and older Established
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
CPT 99397
|
| Hospital Charge Code |
1122833
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.15 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$365.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$365.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.88
|
| Rate for Payer: Health EOS Commercial |
$350.17
|
| Rate for Payer: HFN Commercial |
$365.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$355.19
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$365.56
|
| Rate for Payer: Quartz Beloit One Network |
$169.31
|
| Rate for Payer: Quartz Commercial |
$219.34
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: United Healthcare Medicaid |
$93.15
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
PERIPHERAL AND CRANIAL NERVE DIAGNOSES
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
EAPG 00527
|
| Min. Negotiated Rate |
$27.59 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Anthem Medicaid |
$27.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$27.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.59
|
| Rate for Payer: Dean Health Medicaid |
$27.59
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.59
|
| Rate for Payer: Managed Health Services Medicaid |
$28.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.59
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.59
|
| Rate for Payer: United Healthcare Medicaid |
$27.59
|
|
|
PERIPHERAL AND OTHER VASCULAR DIAGNOSES
|
Facility
|
OP
|
$31.77
|
|
|
Service Code
|
EAPG 00596
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$31.77 |
| Rate for Payer: Anthem Medicaid |
$30.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$30.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.55
|
| Rate for Payer: Dean Health Medicaid |
$30.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.55
|
| Rate for Payer: Managed Health Services Medicaid |
$31.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.55
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.55
|
| Rate for Payer: United Healthcare Medicaid |
$30.55
|
|
|
PERIPHERAL AND OTHER VASCULAR DISORDERS
|
Facility
|
IP
|
$10,785.02
|
|
|
Service Code
|
APR-DRG 1973
|
| Min. Negotiated Rate |
$9,579.93 |
| Max. Negotiated Rate |
$10,785.02 |
| Rate for Payer: Anthem Medicaid |
$10,327.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$10,327.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,327.25
|
| Rate for Payer: Dean Health Medicaid |
$10,327.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9,579.93
|
| Rate for Payer: Managed Health Services Medicaid |
$10,785.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,327.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10,327.25
|
| Rate for Payer: United Healthcare Medicaid |
$10,327.25
|
|
|
PERIPHERAL AND OTHER VASCULAR DISORDERS
|
Facility
|
IP
|
$5,260.99
|
|
|
Service Code
|
APR-DRG 1971
|
| Min. Negotiated Rate |
$4,673.14 |
| Max. Negotiated Rate |
$5,260.99 |
| Rate for Payer: Anthem Medicaid |
$5,037.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,037.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,037.68
|
| Rate for Payer: Dean Health Medicaid |
$5,037.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,673.14
|
| Rate for Payer: Managed Health Services Medicaid |
$5,260.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,037.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,037.68
|
| Rate for Payer: United Healthcare Medicaid |
$5,037.68
|
|
