|
PRESSURE REGULATING BALLON 71-80CM H20 72400025
|
Facility
|
OP
|
$16,160.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,524.80 |
| Max. Negotiated Rate |
$64,640.00 |
| Rate for Payer: Aetna Commercial |
$14,544.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,897.60
|
| Rate for Payer: Aetna Managed Medicare |
$4,524.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,504.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,080.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,756.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,564.80
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$14,867.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,043.14
|
| Rate for Payer: Health EOS Commercial |
$14,382.40
|
| Rate for Payer: HFN Commercial |
$14,867.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,120.00
|
| Rate for Payer: Multiplan Commercial |
$12,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,867.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,918.40
|
| Rate for Payer: Quartz Commercial |
$10,504.00
|
| Rate for Payer: Quartz Medicare Advantage |
$9,696.00
|
| Rate for Payer: The Alliance Commercial |
$64,640.00
|
| Rate for Payer: WEA Trust Commercial |
$8,888.00
|
| Rate for Payer: WPS Commercial |
$11,969.71
|
|
|
PRESSURE REGULATING BALLON 71-80CM H20 72400025
|
Facility
|
IP
|
$16,160.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5563559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,918.40 |
| Max. Negotiated Rate |
$14,867.20 |
| Rate for Payer: Aetna Commercial |
$14,544.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,897.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,564.80
|
| Rate for Payer: Cash Price |
$4,848.00
|
| Rate for Payer: Cigna Commercial |
$14,867.20
|
| Rate for Payer: Health EOS Commercial |
$14,382.40
|
| Rate for Payer: HFN Commercial |
$14,867.20
|
| Rate for Payer: Multiplan Commercial |
$12,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$14,867.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,918.40
|
| Rate for Payer: Quartz Commercial |
$9,696.00
|
| Rate for Payer: WEA Trust Commercial |
$8,888.00
|
| Rate for Payer: WPS Commercial |
$11,969.71
|
|
|
Pre-TR ABO/Rh
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Pre-TR ABO/Rh
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
973777
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$209.59
|
| Rate for Payer: Anthem Medicaid |
$3.09
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Dean Health Medicaid |
$3.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicaid |
$3.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.09
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicaid |
$3.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WMAP Medicaid |
$3.09
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
Pre-Transfusion Reaction ABSC
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$214.24 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$53.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.91
|
| Rate for Payer: Anthem Medicaid |
$5.38
|
| Rate for Payer: Anthem Medicare Advantage |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.56
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Dean Health Medicaid |
$5.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.56
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$80.34
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.38
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$53.56
|
| Rate for Payer: The Alliance Commercial |
$214.24
|
| Rate for Payer: United Healthcare Medicaid |
$5.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.56
|
| Rate for Payer: United Healthcare PPO |
$143.25
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: Wellcare Medicare |
$53.56
|
| Rate for Payer: WMAP Medicaid |
$5.38
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Pre-Transfusion Reaction ABSC
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT 86850
|
| Hospital Charge Code |
973778
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$114.60
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Pre-Transfusion Reaction DAT
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973779
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Pre-Transfusion Reaction DAT
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
973779
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$241.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.36
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$76.50
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Pre-Transfusion Reaction XM
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
973780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.61 |
| Max. Negotiated Rate |
$173.88 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$113.40
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$113.40
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
Pre-Transfusion Reaction XM
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
973780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.61 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.54
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$122.85
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$141.75
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
Preventive Medicine, Individual Counseling; 15 Minutes
|
Professional
|
Both
|
$131.00
|
|
|
Service Code
|
CPT 99401
|
| Hospital Charge Code |
1122875
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$124.45 |
| Rate for Payer: Aetna Commercial |
$124.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.66
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$124.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.60
|
| Rate for Payer: Health EOS Commercial |
$119.21
|
| Rate for Payer: HFN Commercial |
$124.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.64
|
| Rate for Payer: Multiplan Commercial |
$104.80
|
| Rate for Payer: Preferred Network Access Commercial |
$124.45
|
| Rate for Payer: Quartz Beloit One Network |
$57.64
|
| Rate for Payer: Quartz Commercial |
$74.67
|
| Rate for Payer: The Alliance Commercial |
$65.50
|
| Rate for Payer: United Healthcare Medicaid |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$72.05
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
|
PRGRMG DEV EVAL SCRMS PHYS/QHP REMOTE 0650T
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
CPT 0650T
|
| Hospital Charge Code |
5901633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
PRIAPISM, CORRECTION OF/CORPORAL IRRIGATION/PENILE CORPUS CAVERNOSUM REPAIR
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
PRIAPISM, CORRECTION OF/CORPORAL IRRIGATION/PENILE CORPUS CAVERNOSUM REPAIR
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Primatrix per sq cm Q4110
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Primatrix per sq cm Q4110
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$323.00 |
| Rate for Payer: Aetna Commercial |
$323.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$323.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$204.00
|
| Rate for Payer: Health EOS Commercial |
$309.40
|
| Rate for Payer: HFN Commercial |
$323.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$152.74
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: Preferred Network Access Commercial |
$323.00
|
| Rate for Payer: Quartz Beloit One Network |
$149.60
|
| Rate for Payer: Quartz Commercial |
$193.80
|
| Rate for Payer: The Alliance Commercial |
$170.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Primatrix per sq cm Q4110
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
3133677
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$1,360.00 |
| Rate for Payer: Aetna Commercial |
$306.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.40
|
| Rate for Payer: Aetna Managed Medicare |
$95.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$221.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$170.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$163.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.20
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$312.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.26
|
| Rate for Payer: Health EOS Commercial |
$302.60
|
| Rate for Payer: HFN Commercial |
$312.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Multiplan Commercial |
$272.00
|
| Rate for Payer: NAPHCARE Commercial |
$204.00
|
| Rate for Payer: Preferred Network Access Commercial |
$312.80
|
| Rate for Payer: Quartz Beloit One Network |
$166.60
|
| Rate for Payer: Quartz Commercial |
$221.00
|
| Rate for Payer: Quartz Medicare Advantage |
$204.00
|
| Rate for Payer: The Alliance Commercial |
$1,360.00
|
| Rate for Payer: WEA Trust Commercial |
$187.00
|
| Rate for Payer: WPS Commercial |
$251.84
|
|
|
Primewire J 185cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$176.44 |
| Max. Negotiated Rate |
$380.95 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$380.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$200.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.60
|
| Rate for Payer: Health EOS Commercial |
$364.91
|
| Rate for Payer: HFN Commercial |
$380.95
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: Preferred Network Access Commercial |
$380.95
|
| Rate for Payer: Quartz Beloit One Network |
$176.44
|
| Rate for Payer: Quartz Commercial |
$228.57
|
| Rate for Payer: The Alliance Commercial |
$200.50
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire J 185cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.49 |
| Max. Negotiated Rate |
$368.92 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$240.60
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire J 185cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.28 |
| Max. Negotiated Rate |
$1,604.00 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Aetna Managed Medicare |
$112.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.40
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$300.75
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$260.65
|
| Rate for Payer: Quartz Medicare Advantage |
$240.60
|
| Rate for Payer: The Alliance Commercial |
$1,604.00
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire J 300cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.28 |
| Max. Negotiated Rate |
$1,604.00 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Aetna Managed Medicare |
$112.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.40
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$300.75
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$260.65
|
| Rate for Payer: Quartz Medicare Advantage |
$240.60
|
| Rate for Payer: The Alliance Commercial |
$1,604.00
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire J 300cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$196.49 |
| Max. Negotiated Rate |
$368.92 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$240.60
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire J 300cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$176.44 |
| Max. Negotiated Rate |
$380.95 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$380.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$200.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.60
|
| Rate for Payer: Health EOS Commercial |
$364.91
|
| Rate for Payer: HFN Commercial |
$380.95
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: Preferred Network Access Commercial |
$380.95
|
| Rate for Payer: Quartz Beloit One Network |
$176.44
|
| Rate for Payer: Quartz Commercial |
$228.57
|
| Rate for Payer: The Alliance Commercial |
$200.50
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire ST 185cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$176.44 |
| Max. Negotiated Rate |
$380.95 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$380.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$200.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.60
|
| Rate for Payer: Health EOS Commercial |
$364.91
|
| Rate for Payer: HFN Commercial |
$380.95
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: Preferred Network Access Commercial |
$380.95
|
| Rate for Payer: Quartz Beloit One Network |
$176.44
|
| Rate for Payer: Quartz Commercial |
$228.57
|
| Rate for Payer: The Alliance Commercial |
$200.50
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Primewire ST 185cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.28 |
| Max. Negotiated Rate |
$1,604.00 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Aetna Managed Medicare |
$112.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.53
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$368.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.40
|
| Rate for Payer: Health EOS Commercial |
$356.89
|
| Rate for Payer: HFN Commercial |
$368.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$300.75
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: NAPHCARE Commercial |
$240.60
|
| Rate for Payer: Preferred Network Access Commercial |
$368.92
|
| Rate for Payer: Quartz Beloit One Network |
$196.49
|
| Rate for Payer: Quartz Commercial |
$260.65
|
| Rate for Payer: Quartz Medicare Advantage |
$240.60
|
| Rate for Payer: The Alliance Commercial |
$1,604.00
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
