|
SAW BLADE OXFORD KNEE RESECTION PROCEDURE 3 PACK 506298
|
Facility
|
OP
|
$7,181.00
|
|
| Hospital Charge Code |
4595635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,091.11 |
| Max. Negotiated Rate |
$6,870.78 |
| Rate for Payer: Aetna Commercial |
$6,721.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,422.69
|
| Rate for Payer: Aetna Managed Medicare |
$2,091.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,854.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,734.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,584.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.17
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,870.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,179.34
|
| Rate for Payer: Health EOS Commercial |
$6,646.73
|
| Rate for Payer: HFN Commercial |
$6,870.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,601.18
|
| Rate for Payer: Multiplan Commercial |
$5,974.59
|
| Rate for Payer: NAPHCARE Commercial |
$4,480.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,870.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.44
|
| Rate for Payer: Quartz Commercial |
$4,854.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4,480.94
|
| Rate for Payer: The Alliance Commercial |
$3,734.12
|
| Rate for Payer: WEA Trust Commercial |
$4,107.53
|
| Rate for Payer: WPS Commercial |
$5,531.52
|
|
|
SAW BLADE OXFORD KNEE RESECTION PROCEDURE 3 PACK 506298
|
Facility
|
IP
|
$7,181.00
|
|
| Hospital Charge Code |
4595635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,659.44 |
| Max. Negotiated Rate |
$6,870.78 |
| Rate for Payer: Aetna Commercial |
$6,721.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,422.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,958.17
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,870.78
|
| Rate for Payer: Health EOS Commercial |
$6,646.73
|
| Rate for Payer: HFN Commercial |
$6,870.78
|
| Rate for Payer: Multiplan Commercial |
$5,974.59
|
| Rate for Payer: Preferred Network Access Commercial |
$6,870.78
|
| Rate for Payer: Quartz Beloit One Network |
$3,659.44
|
| Rate for Payer: Quartz Commercial |
$4,480.94
|
| Rate for Payer: WEA Trust Commercial |
$4,107.53
|
| Rate for Payer: WPS Commercial |
$5,531.52
|
|
|
SAW BLADE OXFORD KNEE RESECTION STRYKER HUB 506109
|
Facility
|
OP
|
$4,327.00
|
|
| Hospital Charge Code |
6181517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,260.02 |
| Max. Negotiated Rate |
$4,140.07 |
| Rate for Payer: Aetna Commercial |
$4,050.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,870.07
|
| Rate for Payer: Aetna Managed Medicare |
$1,260.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,925.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,250.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,160.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,385.04
|
| Rate for Payer: Cash Price |
$1,298.10
|
| Rate for Payer: Cigna Commercial |
$4,140.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,518.31
|
| Rate for Payer: Health EOS Commercial |
$4,005.07
|
| Rate for Payer: HFN Commercial |
$4,140.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,375.06
|
| Rate for Payer: Multiplan Commercial |
$3,600.06
|
| Rate for Payer: NAPHCARE Commercial |
$2,700.05
|
| Rate for Payer: Preferred Network Access Commercial |
$4,140.07
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.04
|
| Rate for Payer: Quartz Commercial |
$2,925.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,700.05
|
| Rate for Payer: The Alliance Commercial |
$2,250.04
|
| Rate for Payer: WEA Trust Commercial |
$2,475.04
|
| Rate for Payer: WPS Commercial |
$3,333.09
|
|
|
SAW BLADE OXFORD KNEE RESECTION STRYKER HUB 506109
|
Facility
|
IP
|
$4,327.00
|
|
| Hospital Charge Code |
6181517
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,205.04 |
| Max. Negotiated Rate |
$4,140.07 |
| Rate for Payer: Aetna Commercial |
$4,050.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,870.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,385.04
|
| Rate for Payer: Cash Price |
$1,298.10
|
| Rate for Payer: Cigna Commercial |
$4,140.07
|
| Rate for Payer: Health EOS Commercial |
$4,005.07
|
| Rate for Payer: HFN Commercial |
$4,140.07
|
| Rate for Payer: Multiplan Commercial |
$3,600.06
|
| Rate for Payer: Preferred Network Access Commercial |
$4,140.07
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.04
|
| Rate for Payer: Quartz Commercial |
$2,700.05
|
| Rate for Payer: WEA Trust Commercial |
$2,475.04
|
| Rate for Payer: WPS Commercial |
$3,333.09
|
|
|
SCALENOTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960363
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SCALENOTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960363
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
SCALPEL SAFETY DISPOSABLE STERILE #11
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
2963797
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$14.35
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
SCALPEL SAFETY DISPOSABLE STERILE #11
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
2963797
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$21.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.57
|
| Rate for Payer: Aetna Managed Medicare |
$6.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.68
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.39
|
| Rate for Payer: Health EOS Commercial |
$21.29
|
| Rate for Payer: HFN Commercial |
$22.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.94
|
| Rate for Payer: Multiplan Commercial |
$19.14
|
| Rate for Payer: NAPHCARE Commercial |
$14.35
|
| Rate for Payer: Preferred Network Access Commercial |
$22.01
|
| Rate for Payer: Quartz Beloit One Network |
$11.72
|
| Rate for Payer: Quartz Commercial |
$15.55
|
| Rate for Payer: Quartz Medicare Advantage |
$14.35
|
| Rate for Payer: The Alliance Commercial |
$11.96
|
| Rate for Payer: WEA Trust Commercial |
$13.16
|
| Rate for Payer: WPS Commercial |
$17.72
|
|
|
SCALPEL SAFETY DISPOSABLE STERILE 15
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2963796
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$14.98
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
SCALPEL SAFETY DISPOSABLE STERILE 15
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2963796
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Managed Medicare |
$6.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.97
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: NAPHCARE Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: Quartz Medicare Advantage |
$14.98
|
| Rate for Payer: The Alliance Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
SCAN 3 AUDITORY ASSESSMENT
|
Facility
|
IP
|
$1,113.00
|
|
| Hospital Charge Code |
2972031
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$567.18 |
| Max. Negotiated Rate |
$1,064.92 |
| Rate for Payer: Aetna Commercial |
$1,041.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$995.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$613.49
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,064.92
|
| Rate for Payer: Health EOS Commercial |
$1,030.19
|
| Rate for Payer: HFN Commercial |
$1,064.92
|
| Rate for Payer: Multiplan Commercial |
$926.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.92
|
| Rate for Payer: Quartz Beloit One Network |
$567.18
|
| Rate for Payer: Quartz Commercial |
$694.51
|
| Rate for Payer: WEA Trust Commercial |
$636.64
|
| Rate for Payer: WPS Commercial |
$857.34
|
|
|
SCAN 3 AUDITORY ASSESSMENT
|
Facility
|
OP
|
$1,113.00
|
|
| Hospital Charge Code |
2972031
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$324.11 |
| Max. Negotiated Rate |
$1,064.92 |
| Rate for Payer: Aetna Commercial |
$1,041.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$995.47
|
| Rate for Payer: Aetna Managed Medicare |
$324.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$752.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$578.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$555.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$613.49
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,064.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$647.77
|
| Rate for Payer: Health EOS Commercial |
$1,030.19
|
| Rate for Payer: HFN Commercial |
$1,064.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$868.14
|
| Rate for Payer: Multiplan Commercial |
$926.02
|
| Rate for Payer: NAPHCARE Commercial |
$694.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.92
|
| Rate for Payer: Quartz Beloit One Network |
$567.18
|
| Rate for Payer: Quartz Commercial |
$752.39
|
| Rate for Payer: Quartz Medicare Advantage |
$694.51
|
| Rate for Payer: The Alliance Commercial |
$578.76
|
| Rate for Payer: WEA Trust Commercial |
$636.64
|
| Rate for Payer: WPS Commercial |
$857.34
|
|
|
Scan Com Opth Diag 92134
|
Professional
|
Both
|
$170.00
|
|
|
Service Code
|
CPT 92134
|
| Hospital Charge Code |
3568177
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$167.96 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$32.61
|
| Rate for Payer: Anthem Medicare Advantage |
$32.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.61
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$167.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.61
|
| Rate for Payer: Health EOS Commercial |
$160.89
|
| Rate for Payer: HFN Commercial |
$167.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$145.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.61
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$48.92
|
| Rate for Payer: Preferred Network Access Commercial |
$167.96
|
| Rate for Payer: Quartz Beloit One Network |
$77.79
|
| Rate for Payer: Quartz Commercial |
$100.78
|
| Rate for Payer: Quartz Medicare Advantage |
$32.61
|
| Rate for Payer: The Alliance Commercial |
$81.54
|
| Rate for Payer: United Healthcare Medicaid |
$33.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.61
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.46
|
|
|
Scan Com Opth Diag 9213426
|
Professional
|
Both
|
$170.00
|
|
|
Service Code
|
CPT 92134 26
|
| Hospital Charge Code |
3133525
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.87 |
| Max. Negotiated Rate |
$167.96 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$17.87
|
| Rate for Payer: Anthem Medicare Advantage |
$17.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.87
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$167.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.87
|
| Rate for Payer: Health EOS Commercial |
$160.89
|
| Rate for Payer: HFN Commercial |
$167.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$26.80
|
| Rate for Payer: Preferred Network Access Commercial |
$167.96
|
| Rate for Payer: Quartz Beloit One Network |
$77.79
|
| Rate for Payer: Quartz Commercial |
$100.78
|
| Rate for Payer: Quartz Medicare Advantage |
$17.87
|
| Rate for Payer: The Alliance Commercial |
$44.67
|
| Rate for Payer: United Healthcare Medicaid |
$21.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.87
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$71.47
|
|
|
Scan Comp Ophth Di Imag 92133
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 92133
|
| Hospital Charge Code |
3568176
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$164.01 |
| Rate for Payer: Aetna Commercial |
$164.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Aetna Managed Medicare |
$30.60
|
| Rate for Payer: Anthem Medicare Advantage |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.60
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$164.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.60
|
| Rate for Payer: Health EOS Commercial |
$157.10
|
| Rate for Payer: HFN Commercial |
$164.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.60
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: NAPHCARE Commercial |
$45.90
|
| Rate for Payer: Preferred Network Access Commercial |
$164.01
|
| Rate for Payer: Quartz Beloit One Network |
$75.96
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: Quartz Medicare Advantage |
$30.60
|
| Rate for Payer: The Alliance Commercial |
$76.49
|
| Rate for Payer: United Healthcare Medicaid |
$33.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$122.39
|
|
|
Scan Comp Ophth Di Imag 9213326
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
CPT 92133 26
|
| Hospital Charge Code |
3147525
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$164.01 |
| Rate for Payer: Aetna Commercial |
$164.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Medicare Advantage |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.52
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$164.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.52
|
| Rate for Payer: Health EOS Commercial |
$157.10
|
| Rate for Payer: HFN Commercial |
$164.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.52
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: NAPHCARE Commercial |
$24.77
|
| Rate for Payer: Preferred Network Access Commercial |
$164.01
|
| Rate for Payer: Quartz Beloit One Network |
$75.96
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: Quartz Medicare Advantage |
$16.52
|
| Rate for Payer: The Alliance Commercial |
$41.29
|
| Rate for Payer: United Healthcare Medicaid |
$21.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.52
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$66.06
|
|
|
SCAR REVISION
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960364
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SCAR REVISION
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960364
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SCHANZ PIN 5.0 TORNIER ZPSS5
|
Facility
|
OP
|
$1,281.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$373.03 |
| Max. Negotiated Rate |
$1,225.66 |
| Rate for Payer: Aetna Commercial |
$1,199.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.73
|
| Rate for Payer: Aetna Managed Medicare |
$373.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$865.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$666.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$639.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$706.09
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,225.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$745.54
|
| Rate for Payer: Health EOS Commercial |
$1,185.69
|
| Rate for Payer: HFN Commercial |
$1,225.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$999.18
|
| Rate for Payer: Multiplan Commercial |
$1,065.79
|
| Rate for Payer: NAPHCARE Commercial |
$799.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.66
|
| Rate for Payer: Quartz Beloit One Network |
$652.80
|
| Rate for Payer: Quartz Commercial |
$865.96
|
| Rate for Payer: Quartz Medicare Advantage |
$799.34
|
| Rate for Payer: The Alliance Commercial |
$666.12
|
| Rate for Payer: WEA Trust Commercial |
$732.73
|
| Rate for Payer: WPS Commercial |
$986.75
|
|
|
SCHANZ PIN 5.0 TORNIER ZPSS5
|
Facility
|
IP
|
$1,281.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.80 |
| Max. Negotiated Rate |
$1,225.66 |
| Rate for Payer: Aetna Commercial |
$1,199.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,145.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$706.09
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,225.66
|
| Rate for Payer: Health EOS Commercial |
$1,185.69
|
| Rate for Payer: HFN Commercial |
$1,225.66
|
| Rate for Payer: Multiplan Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,225.66
|
| Rate for Payer: Quartz Beloit One Network |
$652.80
|
| Rate for Payer: Quartz Commercial |
$799.34
|
| Rate for Payer: WEA Trust Commercial |
$732.73
|
| Rate for Payer: WPS Commercial |
$986.75
|
|
|
Schistosoma Antibody (IgG), FMI
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
5242622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$13.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.46
|
| Rate for Payer: Anthem Medicare Advantage |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.53
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.53
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.53
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$20.30
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$59.49
|
| Rate for Payer: Quartz Medicare Advantage |
$13.53
|
| Rate for Payer: The Alliance Commercial |
$54.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.53
|
| Rate for Payer: United Healthcare PPO |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: Wellcare Medicare |
$13.53
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
Schistosoma Antibody (IgG), FMI
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
5242622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$86.94 |
| Rate for Payer: Aetna Commercial |
$86.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$13.53
|
| Rate for Payer: Anthem Medicare Advantage |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.53
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$86.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.53
|
| Rate for Payer: Health EOS Commercial |
$83.28
|
| Rate for Payer: HFN Commercial |
$86.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.53
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$20.30
|
| Rate for Payer: Preferred Network Access Commercial |
$86.94
|
| Rate for Payer: Quartz Beloit One Network |
$40.27
|
| Rate for Payer: Quartz Commercial |
$52.17
|
| Rate for Payer: Quartz Medicare Advantage |
$13.53
|
| Rate for Payer: The Alliance Commercial |
$53.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.53
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$59.53
|
|
|
Schistosoma Antibody (IgG), FMI
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
5242622
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$7,102.33
|
|
|
Service Code
|
APR-DRG 7612
|
| Min. Negotiated Rate |
$6,308.73 |
| Max. Negotiated Rate |
$7,102.33 |
| Rate for Payer: Anthem Medicaid |
$6,800.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,800.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,800.87
|
| Rate for Payer: Dean Health Medicaid |
$6,800.87
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,308.73
|
| Rate for Payer: Managed Health Services Medicaid |
$7,102.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,800.87
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,800.87
|
| Rate for Payer: United Healthcare Medicaid |
$6,800.87
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$6,751.60
|
|
|
Service Code
|
APR-DRG 7611
|
| Min. Negotiated Rate |
$5,997.19 |
| Max. Negotiated Rate |
$6,751.60 |
| Rate for Payer: Anthem Medicaid |
$6,465.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,465.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,465.03
|
| Rate for Payer: Dean Health Medicaid |
$6,465.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,997.19
|
| Rate for Payer: Managed Health Services Medicaid |
$6,751.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,465.03
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,465.03
|
| Rate for Payer: United Healthcare Medicaid |
$6,465.03
|
|
