|
PRECISION PIN GAMMA4 3.2/3.9 X 450MM TAPERED 1420-0065S
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
6181748
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,346.80 |
| Max. Negotiated Rate |
$4,425.20 |
| Rate for Payer: Aetna Commercial |
$4,329.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,136.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,346.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,126.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,405.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,308.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,549.30
|
| Rate for Payer: Cash Price |
$1,387.50
|
| Rate for Payer: Cigna Commercial |
$4,425.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,691.75
|
| Rate for Payer: Health EOS Commercial |
$4,280.90
|
| Rate for Payer: HFN Commercial |
$4,425.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,607.50
|
| Rate for Payer: Multiplan Commercial |
$3,848.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,886.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,425.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,356.90
|
| Rate for Payer: Quartz Commercial |
$3,126.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,886.00
|
| Rate for Payer: The Alliance Commercial |
$2,405.00
|
| Rate for Payer: WEA Trust Commercial |
$2,645.50
|
| Rate for Payer: WPS Commercial |
$3,562.64
|
|
|
PRECISION PIN GAMMA4 3.2/3.9 X 450MM TAPERED 1420-0065S
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
6181748
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,356.90 |
| Max. Negotiated Rate |
$4,425.20 |
| Rate for Payer: Aetna Commercial |
$4,329.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,136.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,549.30
|
| Rate for Payer: Cash Price |
$1,387.50
|
| Rate for Payer: Cigna Commercial |
$4,425.20
|
| Rate for Payer: Health EOS Commercial |
$4,280.90
|
| Rate for Payer: HFN Commercial |
$4,425.20
|
| Rate for Payer: Multiplan Commercial |
$3,848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,425.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,356.90
|
| Rate for Payer: Quartz Commercial |
$2,886.00
|
| Rate for Payer: WEA Trust Commercial |
$2,645.50
|
| Rate for Payer: WPS Commercial |
$3,562.64
|
|
|
PRE CUT POLYFORM MED.
|
Facility
|
IP
|
$229.00
|
|
| Hospital Charge Code |
2971397
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$142.90
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
PRE CUT POLYFORM MED.
|
Facility
|
OP
|
$229.00
|
|
| Hospital Charge Code |
2971397
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.68 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Aetna Managed Medicare |
$66.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.28
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.62
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: NAPHCARE Commercial |
$142.90
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: Quartz Medicare Advantage |
$142.90
|
| Rate for Payer: The Alliance Commercial |
$119.08
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
Prednisolone 1% Ophth Suspension 5ml [Med]
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2974973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$106.70
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
Prednisolone 1% Ophth Suspension 5ml [Med]
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2974973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$163.61 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.94
|
| Rate for Payer: Aetna Managed Medicare |
$49.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.26
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$163.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.52
|
| Rate for Payer: Health EOS Commercial |
$158.28
|
| Rate for Payer: HFN Commercial |
$163.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$133.38
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: NAPHCARE Commercial |
$106.70
|
| Rate for Payer: Preferred Network Access Commercial |
$163.61
|
| Rate for Payer: Quartz Beloit One Network |
$87.14
|
| Rate for Payer: Quartz Commercial |
$115.60
|
| Rate for Payer: Quartz Medicare Advantage |
$106.70
|
| Rate for Payer: The Alliance Commercial |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$97.81
|
| Rate for Payer: WPS Commercial |
$131.72
|
|
|
Prednisone oral 1 mg J7512
|
Professional
|
Both
|
$6.00
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
5492829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5.93 |
| Rate for Payer: Aetna Commercial |
$5.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$5.68
|
| Rate for Payer: HFN Commercial |
$5.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.93
|
| Rate for Payer: Quartz Beloit One Network |
$2.75
|
| Rate for Payer: Quartz Commercial |
$3.56
|
| Rate for Payer: United Healthcare Medicaid |
$0.01
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$0.02
|
|
|
Prednisone oral 1 mg J7512
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
5492829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Prednisone oral 1 mg J7512
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
5492829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$0.02
|
|
|
Pregabalin Level
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5812131
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$401.86 |
| Rate for Payer: Aetna Commercial |
$393.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.65
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$231.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$401.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$244.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$388.75
|
| Rate for Payer: HFN Commercial |
$401.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$349.44
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$401.86
|
| Rate for Payer: Quartz Beloit One Network |
$214.03
|
| Rate for Payer: Quartz Commercial |
$283.92
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$327.60
|
| Rate for Payer: WEA Trust Commercial |
$240.24
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$323.53
|
|
|
Pregabalin Level
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5812131
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$414.96 |
| Rate for Payer: Aetna Commercial |
$414.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.65
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$414.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$218.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$397.49
|
| Rate for Payer: HFN Commercial |
$414.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$349.44
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$414.96
|
| Rate for Payer: Quartz Beloit One Network |
$192.19
|
| Rate for Payer: Quartz Commercial |
$248.98
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$240.24
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Pregabalin Level
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5812131
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$214.03 |
| Max. Negotiated Rate |
$401.86 |
| Rate for Payer: Aetna Commercial |
$393.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$231.50
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$401.86
|
| Rate for Payer: Health EOS Commercial |
$388.75
|
| Rate for Payer: HFN Commercial |
$401.86
|
| Rate for Payer: Multiplan Commercial |
$349.44
|
| Rate for Payer: Preferred Network Access Commercial |
$401.86
|
| Rate for Payer: Quartz Beloit One Network |
$214.03
|
| Rate for Payer: Quartz Commercial |
$262.08
|
| Rate for Payer: WEA Trust Commercial |
$240.24
|
| Rate for Payer: WPS Commercial |
$323.53
|
|
|
Pregnancy Test Urine
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
1006872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.86
|
| Rate for Payer: Anthem Medicare Advantage |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.95
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.95
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$13.43
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: Quartz Medicare Advantage |
$8.95
|
| Rate for Payer: The Alliance Commercial |
$35.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.95
|
| Rate for Payer: United Healthcare PPO |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: Wellcare Medicare |
$8.95
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
Pregnancy Test Urine
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
1006872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.61 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$104.83
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
Pregnancy Test Urine
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
1006872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$165.98 |
| Rate for Payer: Aetna Commercial |
$165.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$8.95
|
| Rate for Payer: Anthem Medicare Advantage |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.95
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$165.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.95
|
| Rate for Payer: Health EOS Commercial |
$159.00
|
| Rate for Payer: HFN Commercial |
$165.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$13.43
|
| Rate for Payer: Preferred Network Access Commercial |
$165.98
|
| Rate for Payer: Quartz Beloit One Network |
$76.88
|
| Rate for Payer: Quartz Commercial |
$99.59
|
| Rate for Payer: Quartz Medicare Advantage |
$8.95
|
| Rate for Payer: The Alliance Commercial |
$35.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.95
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$39.40
|
|
|
Pregnenolone, LC/MS/MS
|
Professional
|
Both
|
$362.00
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
983367
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$357.66 |
| Rate for Payer: Aetna Commercial |
$357.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$323.77
|
| Rate for Payer: Aetna Managed Medicare |
$21.50
|
| Rate for Payer: Anthem Medicare Advantage |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.50
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$357.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$188.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.50
|
| Rate for Payer: Health EOS Commercial |
$342.60
|
| Rate for Payer: HFN Commercial |
$357.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$301.18
|
| Rate for Payer: NAPHCARE Commercial |
$32.25
|
| Rate for Payer: Preferred Network Access Commercial |
$357.66
|
| Rate for Payer: Quartz Beloit One Network |
$165.65
|
| Rate for Payer: Quartz Commercial |
$214.59
|
| Rate for Payer: Quartz Medicare Advantage |
$21.50
|
| Rate for Payer: The Alliance Commercial |
$84.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.50
|
| Rate for Payer: WEA Trust Commercial |
$207.06
|
| Rate for Payer: WPS Commercial |
$94.59
|
|
|
Pregnenolone, LC/MS/MS
|
Facility
|
OP
|
$362.00
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
983367
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$346.36 |
| Rate for Payer: Aetna Commercial |
$338.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$323.77
|
| Rate for Payer: Aetna Managed Medicare |
$21.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.68
|
| Rate for Payer: Anthem Medicare Advantage |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$199.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.50
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$346.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.50
|
| Rate for Payer: Health EOS Commercial |
$335.07
|
| Rate for Payer: HFN Commercial |
$346.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$301.18
|
| Rate for Payer: NAPHCARE Commercial |
$32.25
|
| Rate for Payer: Preferred Network Access Commercial |
$346.36
|
| Rate for Payer: Quartz Beloit One Network |
$184.48
|
| Rate for Payer: Quartz Commercial |
$244.71
|
| Rate for Payer: Quartz Medicare Advantage |
$21.50
|
| Rate for Payer: The Alliance Commercial |
$85.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.50
|
| Rate for Payer: United Healthcare PPO |
$282.36
|
| Rate for Payer: WEA Trust Commercial |
$207.06
|
| Rate for Payer: Wellcare Medicare |
$21.50
|
| Rate for Payer: WPS Commercial |
$278.85
|
|
|
Pregnenolone, LC/MS/MS
|
Facility
|
IP
|
$362.00
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
983367
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$184.48 |
| Max. Negotiated Rate |
$346.36 |
| Rate for Payer: Aetna Commercial |
$338.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$323.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$199.53
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$346.36
|
| Rate for Payer: Health EOS Commercial |
$335.07
|
| Rate for Payer: HFN Commercial |
$346.36
|
| Rate for Payer: Multiplan Commercial |
$301.18
|
| Rate for Payer: Preferred Network Access Commercial |
$346.36
|
| Rate for Payer: Quartz Beloit One Network |
$184.48
|
| Rate for Payer: Quartz Commercial |
$225.89
|
| Rate for Payer: WEA Trust Commercial |
$207.06
|
| Rate for Payer: WPS Commercial |
$278.85
|
|
|
Preg Serum
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$7.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.98
|
| Rate for Payer: Anthem Medicare Advantage |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.82
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.82
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$11.73
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$7.82
|
| Rate for Payer: The Alliance Commercial |
$31.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.82
|
| Rate for Payer: United Healthcare PPO |
$108.42
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: Wellcare Medicare |
$7.82
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Preg Serum
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Preg Serum
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
993778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Aetna Commercial |
$137.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$7.82
|
| Rate for Payer: Anthem Medicare Advantage |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.82
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$137.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.82
|
| Rate for Payer: Health EOS Commercial |
$131.55
|
| Rate for Payer: HFN Commercial |
$137.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$11.73
|
| Rate for Payer: Preferred Network Access Commercial |
$137.33
|
| Rate for Payer: Quartz Beloit One Network |
$63.61
|
| Rate for Payer: Quartz Commercial |
$82.40
|
| Rate for Payer: Quartz Medicare Advantage |
$7.82
|
| Rate for Payer: The Alliance Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.82
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$34.41
|
|
|
PREMATURITY WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$113,632.48
|
|
|
Service Code
|
MSDRG 791
|
| Min. Negotiated Rate |
$2,496.00 |
| Max. Negotiated Rate |
$113,632.48 |
| Rate for Payer: Aetna Managed Medicare |
$31,591.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,242.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,583.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,403.92
|
| Rate for Payer: Anthem Medicare Advantage |
$31,591.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31,591.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31,591.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$31,591.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71,594.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$31,591.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,108.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31,591.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31,591.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$31,591.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$31,591.41
|
| Rate for Payer: NAPHCARE Commercial |
$47,387.12
|
| Rate for Payer: Quartz Medicare Advantage |
$31,591.41
|
| Rate for Payer: The Alliance Commercial |
$113,632.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31,591.41
|
| Rate for Payer: United Healthcare PPO |
$2,496.00
|
| Rate for Payer: Wellcare Medicare |
$31,591.41
|
|
|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$68,696.16
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$1,664.00 |
| Max. Negotiated Rate |
$68,696.16 |
| Rate for Payer: Aetna Managed Medicare |
$19,263.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,702.48
|
| Rate for Payer: Anthem Medicare Advantage |
$19,263.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,263.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,263.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,263.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43,199.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,263.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,016.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,263.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,263.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,263.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,263.24
|
| Rate for Payer: NAPHCARE Commercial |
$28,894.87
|
| Rate for Payer: Quartz Medicare Advantage |
$19,263.24
|
| Rate for Payer: The Alliance Commercial |
$68,696.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,263.24
|
| Rate for Payer: United Healthcare PPO |
$1,664.00
|
| Rate for Payer: Wellcare Medicare |
$19,263.24
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
IP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,487.87 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,046.37
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
|
PREMIUM LUXURY ORTHO #PLS-9519
|
Facility
|
OP
|
$4,882.00
|
|
| Hospital Charge Code |
2973549
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,421.64 |
| Max. Negotiated Rate |
$4,671.10 |
| Rate for Payer: Aetna Commercial |
$4,569.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,366.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,421.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,300.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,538.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,437.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,690.96
|
| Rate for Payer: Cash Price |
$1,464.60
|
| Rate for Payer: Cigna Commercial |
$4,671.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,841.32
|
| Rate for Payer: Health EOS Commercial |
$4,518.78
|
| Rate for Payer: HFN Commercial |
$4,671.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,807.96
|
| Rate for Payer: Multiplan Commercial |
$4,061.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,046.37
|
| Rate for Payer: Preferred Network Access Commercial |
$4,671.10
|
| Rate for Payer: Quartz Beloit One Network |
$2,487.87
|
| Rate for Payer: Quartz Commercial |
$3,300.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,046.37
|
| Rate for Payer: The Alliance Commercial |
$2,538.64
|
| Rate for Payer: WEA Trust Commercial |
$2,792.50
|
| Rate for Payer: WPS Commercial |
$3,760.60
|
|
