|
Platelet (FS)
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
4538808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Platelet Function Assay
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4464657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$25.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.00
|
| Rate for Payer: Anthem Medicare Advantage |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.91
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.91
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$38.86
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$25.91
|
| Rate for Payer: The Alliance Commercial |
$103.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.91
|
| Rate for Payer: United Healthcare PPO |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: Wellcare Medicare |
$25.91
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Platelet Function Assay
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4464657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$268.74 |
| Rate for Payer: Aetna Commercial |
$268.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$25.91
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.91
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$268.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.91
|
| Rate for Payer: Health EOS Commercial |
$257.42
|
| Rate for Payer: HFN Commercial |
$268.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.91
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$38.86
|
| Rate for Payer: Preferred Network Access Commercial |
$268.74
|
| Rate for Payer: Quartz Beloit One Network |
$124.47
|
| Rate for Payer: Quartz Commercial |
$161.24
|
| Rate for Payer: Quartz Medicare Advantage |
$25.91
|
| Rate for Payer: The Alliance Commercial |
$102.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.91
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$113.99
|
|
|
Platelet Function Assay
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4464657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Platelet IgA Indirect
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500768
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.82 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$85.49
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
Platelet IgA Indirect
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500768
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.71
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$92.61
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$76.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: United Healthcare PPO |
$106.86
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: Wellcare Medicare |
$19.10
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
Platelet IgA Indirect
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500768
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$135.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$129.66
|
| Rate for Payer: HFN Commercial |
$135.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$135.36
|
| Rate for Payer: Quartz Beloit One Network |
$62.69
|
| Rate for Payer: Quartz Commercial |
$81.21
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$75.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$84.06
|
|
|
Platelet IgG Indirect
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500766
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$135.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$129.66
|
| Rate for Payer: HFN Commercial |
$135.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$135.36
|
| Rate for Payer: Quartz Beloit One Network |
$62.69
|
| Rate for Payer: Quartz Commercial |
$81.21
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$75.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$84.06
|
|
|
Platelet IgG Indirect
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500766
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.71
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$92.61
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$76.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: United Healthcare PPO |
$106.86
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: Wellcare Medicare |
$19.10
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
Platelet IgG Indirect
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500766
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.82 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$85.49
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
Platelet IgM Indirect
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.82 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$85.49
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
Platelet IgM Indirect
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$135.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$129.66
|
| Rate for Payer: HFN Commercial |
$135.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$135.36
|
| Rate for Payer: Quartz Beloit One Network |
$62.69
|
| Rate for Payer: Quartz Commercial |
$81.21
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$75.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$84.06
|
|
|
Platelet IgM Indirect
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
4500767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$19.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.71
|
| Rate for Payer: Anthem Medicare Advantage |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.10
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.10
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$28.66
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$92.61
|
| Rate for Payer: Quartz Medicare Advantage |
$19.10
|
| Rate for Payer: The Alliance Commercial |
$76.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.10
|
| Rate for Payer: United Healthcare PPO |
$106.86
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: Wellcare Medicare |
$19.10
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
PLATE LOCKING CALCANEAL 241.623
|
Facility
|
OP
|
$6,412.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,867.17 |
| Max. Negotiated Rate |
$6,135.00 |
| Rate for Payer: Aetna Commercial |
$6,001.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,734.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,867.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,334.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,334.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,200.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,534.29
|
| Rate for Payer: Cash Price |
$1,923.60
|
| Rate for Payer: Cigna Commercial |
$6,135.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,731.78
|
| Rate for Payer: Health EOS Commercial |
$5,934.95
|
| Rate for Payer: HFN Commercial |
$6,135.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,001.36
|
| Rate for Payer: Multiplan Commercial |
$5,334.78
|
| Rate for Payer: NAPHCARE Commercial |
$4,001.09
|
| Rate for Payer: Preferred Network Access Commercial |
$6,135.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,267.56
|
| Rate for Payer: Quartz Commercial |
$4,334.51
|
| Rate for Payer: Quartz Medicare Advantage |
$4,001.09
|
| Rate for Payer: The Alliance Commercial |
$3,334.24
|
| Rate for Payer: WEA Trust Commercial |
$3,667.66
|
| Rate for Payer: WPS Commercial |
$4,939.16
|
|
|
PLATE LOCKING CALCANEAL 241.623
|
Facility
|
IP
|
$6,412.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,267.56 |
| Max. Negotiated Rate |
$6,135.00 |
| Rate for Payer: Aetna Commercial |
$6,001.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,734.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,534.29
|
| Rate for Payer: Cash Price |
$1,923.60
|
| Rate for Payer: Cigna Commercial |
$6,135.00
|
| Rate for Payer: Health EOS Commercial |
$5,934.95
|
| Rate for Payer: HFN Commercial |
$6,135.00
|
| Rate for Payer: Multiplan Commercial |
$5,334.78
|
| Rate for Payer: Preferred Network Access Commercial |
$6,135.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,267.56
|
| Rate for Payer: Quartz Commercial |
$4,001.09
|
| Rate for Payer: WEA Trust Commercial |
$3,667.66
|
| Rate for Payer: WPS Commercial |
$4,939.16
|
|
|
PLATE MATRIX MANDIBLE 2.0MM 12HL 04.503.729
|
Facility
|
IP
|
$7,728.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,938.19 |
| Max. Negotiated Rate |
$7,394.15 |
| Rate for Payer: Aetna Commercial |
$7,233.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,911.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,259.67
|
| Rate for Payer: Cash Price |
$2,318.40
|
| Rate for Payer: Cigna Commercial |
$7,394.15
|
| Rate for Payer: Health EOS Commercial |
$7,153.04
|
| Rate for Payer: HFN Commercial |
$7,394.15
|
| Rate for Payer: Multiplan Commercial |
$6,429.70
|
| Rate for Payer: Preferred Network Access Commercial |
$7,394.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,938.19
|
| Rate for Payer: Quartz Commercial |
$4,822.27
|
| Rate for Payer: WEA Trust Commercial |
$4,420.42
|
| Rate for Payer: WPS Commercial |
$5,952.88
|
|
|
PLATE MATRIX MANDIBLE 2.0MM 12HL 04.503.729
|
Facility
|
OP
|
$7,728.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,250.39 |
| Max. Negotiated Rate |
$7,394.15 |
| Rate for Payer: Aetna Commercial |
$7,233.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,911.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,250.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,224.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,018.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,857.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,259.67
|
| Rate for Payer: Cash Price |
$2,318.40
|
| Rate for Payer: Cigna Commercial |
$7,394.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,497.70
|
| Rate for Payer: Health EOS Commercial |
$7,153.04
|
| Rate for Payer: HFN Commercial |
$7,394.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,027.84
|
| Rate for Payer: Multiplan Commercial |
$6,429.70
|
| Rate for Payer: NAPHCARE Commercial |
$4,822.27
|
| Rate for Payer: Preferred Network Access Commercial |
$7,394.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,938.19
|
| Rate for Payer: Quartz Commercial |
$5,224.13
|
| Rate for Payer: Quartz Medicare Advantage |
$4,822.27
|
| Rate for Payer: The Alliance Commercial |
$4,018.56
|
| Rate for Payer: WEA Trust Commercial |
$4,420.42
|
| Rate for Payer: WPS Commercial |
$5,952.88
|
|
|
PLATE MATRIX MANDIBLE RECONSTRUCTION 2.5MM 12HL 04.503.737
|
Facility
|
IP
|
$9,121.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,648.06 |
| Max. Negotiated Rate |
$8,726.97 |
| Rate for Payer: Aetna Commercial |
$8,537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,157.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,027.50
|
| Rate for Payer: Cash Price |
$2,736.30
|
| Rate for Payer: Cigna Commercial |
$8,726.97
|
| Rate for Payer: Health EOS Commercial |
$8,442.40
|
| Rate for Payer: HFN Commercial |
$8,726.97
|
| Rate for Payer: Multiplan Commercial |
$7,588.67
|
| Rate for Payer: Preferred Network Access Commercial |
$8,726.97
|
| Rate for Payer: Quartz Beloit One Network |
$4,648.06
|
| Rate for Payer: Quartz Commercial |
$5,691.50
|
| Rate for Payer: WEA Trust Commercial |
$5,217.21
|
| Rate for Payer: WPS Commercial |
$7,025.91
|
|
|
PLATE MATRIX MANDIBLE RECONSTRUCTION 2.5MM 12HL 04.503.737
|
Facility
|
OP
|
$9,121.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185033
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,656.04 |
| Max. Negotiated Rate |
$8,726.97 |
| Rate for Payer: Aetna Commercial |
$8,537.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,157.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,656.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,165.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,742.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,553.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,027.50
|
| Rate for Payer: Cash Price |
$2,736.30
|
| Rate for Payer: Cigna Commercial |
$8,726.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,308.42
|
| Rate for Payer: Health EOS Commercial |
$8,442.40
|
| Rate for Payer: HFN Commercial |
$8,726.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,114.38
|
| Rate for Payer: Multiplan Commercial |
$7,588.67
|
| Rate for Payer: NAPHCARE Commercial |
$5,691.50
|
| Rate for Payer: Preferred Network Access Commercial |
$8,726.97
|
| Rate for Payer: Quartz Beloit One Network |
$4,648.06
|
| Rate for Payer: Quartz Commercial |
$6,165.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,691.50
|
| Rate for Payer: The Alliance Commercial |
$4,742.92
|
| Rate for Payer: WEA Trust Commercial |
$5,217.21
|
| Rate for Payer: WPS Commercial |
$7,025.91
|
|
|
PLATE MATRIX WAVE MMF 10HL SHORT 04.503.820
|
Facility
|
IP
|
$4,778.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,434.87 |
| Max. Negotiated Rate |
$4,571.59 |
| Rate for Payer: Aetna Commercial |
$4,472.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,273.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,633.63
|
| Rate for Payer: Cash Price |
$1,433.40
|
| Rate for Payer: Cigna Commercial |
$4,571.59
|
| Rate for Payer: Health EOS Commercial |
$4,422.52
|
| Rate for Payer: HFN Commercial |
$4,571.59
|
| Rate for Payer: Multiplan Commercial |
$3,975.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,571.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,434.87
|
| Rate for Payer: Quartz Commercial |
$2,981.47
|
| Rate for Payer: WEA Trust Commercial |
$2,733.02
|
| Rate for Payer: WPS Commercial |
$3,680.49
|
|
|
PLATE MATRIX WAVE MMF 10HL SHORT 04.503.820
|
Facility
|
OP
|
$4,778.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,391.35 |
| Max. Negotiated Rate |
$4,571.59 |
| Rate for Payer: Aetna Commercial |
$4,472.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,273.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,391.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,229.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,484.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,385.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,633.63
|
| Rate for Payer: Cash Price |
$1,433.40
|
| Rate for Payer: Cigna Commercial |
$4,571.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,780.80
|
| Rate for Payer: Health EOS Commercial |
$4,422.52
|
| Rate for Payer: HFN Commercial |
$4,571.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,726.84
|
| Rate for Payer: Multiplan Commercial |
$3,975.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,981.47
|
| Rate for Payer: Preferred Network Access Commercial |
$4,571.59
|
| Rate for Payer: Quartz Beloit One Network |
$2,434.87
|
| Rate for Payer: Quartz Commercial |
$3,229.93
|
| Rate for Payer: Quartz Medicare Advantage |
$2,981.47
|
| Rate for Payer: The Alliance Commercial |
$2,484.56
|
| Rate for Payer: WEA Trust Commercial |
$2,733.02
|
| Rate for Payer: WPS Commercial |
$3,680.49
|
|
|
PLATE MEDIAL DISTAL HUMERUS
|
Facility
|
IP
|
$6,961.00
|
|
| Hospital Charge Code |
2966372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,547.33 |
| Max. Negotiated Rate |
$6,660.28 |
| Rate for Payer: Aetna Commercial |
$6,515.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,225.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,836.90
|
| Rate for Payer: Cash Price |
$2,088.30
|
| Rate for Payer: Cigna Commercial |
$6,660.28
|
| Rate for Payer: Health EOS Commercial |
$6,443.10
|
| Rate for Payer: HFN Commercial |
$6,660.28
|
| Rate for Payer: Multiplan Commercial |
$5,791.55
|
| Rate for Payer: Preferred Network Access Commercial |
$6,660.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,547.33
|
| Rate for Payer: Quartz Commercial |
$4,343.66
|
| Rate for Payer: WEA Trust Commercial |
$3,981.69
|
| Rate for Payer: WPS Commercial |
$5,362.06
|
|
|
PLATE MEDIAL DISTAL HUMERUS
|
Facility
|
OP
|
$6,961.00
|
|
| Hospital Charge Code |
2966372
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,027.04 |
| Max. Negotiated Rate |
$6,660.28 |
| Rate for Payer: Aetna Commercial |
$6,515.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,225.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,027.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,705.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,619.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,474.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,836.90
|
| Rate for Payer: Cash Price |
$2,088.30
|
| Rate for Payer: Cigna Commercial |
$6,660.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,051.30
|
| Rate for Payer: Health EOS Commercial |
$6,443.10
|
| Rate for Payer: HFN Commercial |
$6,660.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,429.58
|
| Rate for Payer: Multiplan Commercial |
$5,791.55
|
| Rate for Payer: NAPHCARE Commercial |
$4,343.66
|
| Rate for Payer: Preferred Network Access Commercial |
$6,660.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,547.33
|
| Rate for Payer: Quartz Commercial |
$4,705.64
|
| Rate for Payer: Quartz Medicare Advantage |
$4,343.66
|
| Rate for Payer: The Alliance Commercial |
$3,619.72
|
| Rate for Payer: WEA Trust Commercial |
$3,981.69
|
| Rate for Payer: WPS Commercial |
$5,362.06
|
|
|
PLATE MEDIAL TIBIA LT MD ORTHOLOC 3DI PLATING SYSTEM 5888802L
|
Facility
|
IP
|
$11,022.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,616.81 |
| Max. Negotiated Rate |
$10,545.85 |
| Rate for Payer: Aetna Commercial |
$10,316.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,858.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,075.33
|
| Rate for Payer: Cash Price |
$3,306.60
|
| Rate for Payer: Cigna Commercial |
$10,545.85
|
| Rate for Payer: Health EOS Commercial |
$10,201.96
|
| Rate for Payer: HFN Commercial |
$10,545.85
|
| Rate for Payer: Multiplan Commercial |
$9,170.30
|
| Rate for Payer: Preferred Network Access Commercial |
$10,545.85
|
| Rate for Payer: Quartz Beloit One Network |
$5,616.81
|
| Rate for Payer: Quartz Commercial |
$6,877.73
|
| Rate for Payer: WEA Trust Commercial |
$6,304.58
|
| Rate for Payer: WPS Commercial |
$8,490.25
|
|
|
PLATE MEDIAL TIBIA LT MD ORTHOLOC 3DI PLATING SYSTEM 5888802L
|
Facility
|
OP
|
$11,022.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,209.61 |
| Max. Negotiated Rate |
$10,545.85 |
| Rate for Payer: Aetna Commercial |
$10,316.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,858.08
|
| Rate for Payer: Aetna Managed Medicare |
$3,209.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,450.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,731.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,502.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,075.33
|
| Rate for Payer: Cash Price |
$3,306.60
|
| Rate for Payer: Cigna Commercial |
$10,545.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,414.80
|
| Rate for Payer: Health EOS Commercial |
$10,201.96
|
| Rate for Payer: HFN Commercial |
$10,545.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,597.16
|
| Rate for Payer: Multiplan Commercial |
$9,170.30
|
| Rate for Payer: NAPHCARE Commercial |
$6,877.73
|
| Rate for Payer: Preferred Network Access Commercial |
$10,545.85
|
| Rate for Payer: Quartz Beloit One Network |
$5,616.81
|
| Rate for Payer: Quartz Commercial |
$7,450.87
|
| Rate for Payer: Quartz Medicare Advantage |
$6,877.73
|
| Rate for Payer: The Alliance Commercial |
$5,731.44
|
| Rate for Payer: WEA Trust Commercial |
$6,304.58
|
| Rate for Payer: WPS Commercial |
$8,490.25
|
|
