|
Sm-153 Lexidronam(per 50 mCi)
|
Facility
IP
|
$14,944.00
|
|
|
Service Code
|
HCPCS A9604
|
| Hospital Charge Code |
1486846
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$7,322.56 |
| Max. Negotiated Rate |
$13,748.48 |
| Rate for Payer: Aetna Commercial |
$13,449.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,920.32
|
| Rate for Payer: Cash Price |
$4,483.20
|
| Rate for Payer: Cigna Commercial |
$13,748.48
|
| Rate for Payer: Health EOS Commercial |
$13,300.16
|
| Rate for Payer: HFN Commercial |
$13,748.48
|
| Rate for Payer: Multiplan Commercial |
$11,955.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,966.40
|
| Rate for Payer: Preferred Network Access Commercial |
$13,748.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,322.56
|
| Rate for Payer: Quartz Commercial |
$8,966.40
|
| Rate for Payer: WEA Trust Commercial |
$8,219.20
|
| Rate for Payer: WPS Commercial |
$11,069.02
|
|
|
SMA Carrier Screen
|
Facility
IP
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$662.97 |
| Max. Negotiated Rate |
$1,244.76 |
| Rate for Payer: Aetna Commercial |
$1,217.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$717.09
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,244.76
|
| Rate for Payer: Health EOS Commercial |
$1,204.17
|
| Rate for Payer: HFN Commercial |
$1,244.76
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$811.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,244.76
|
| Rate for Payer: Quartz Beloit One Network |
$662.97
|
| Rate for Payer: Quartz Commercial |
$811.80
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: WPS Commercial |
$1,002.17
|
|
|
SMA Carrier Screen
|
Facility
OP
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$5,412.00 |
| Rate for Payer: Aetna Commercial |
$1,217.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,163.58
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$513.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.42
|
| Rate for Payer: Anthem Medicaid |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$717.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,244.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,204.17
|
| Rate for Payer: HFN Commercial |
$1,244.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$509.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Managed Health Services Medicaid |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: NAPHCARE Commercial |
$205.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,244.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$137.00
|
| Rate for Payer: Quartz Beloit One Network |
$662.97
|
| Rate for Payer: Quartz Commercial |
$879.45
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$5,412.00
|
| Rate for Payer: United Healthcare Medicaid |
$137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: United Healthcare PPO |
$1,014.75
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: Wellcare Medicare |
$137.00
|
| Rate for Payer: WMAP Medicaid |
$137.00
|
| Rate for Payer: WPS Commercial |
$1,002.17
|
|
|
SMA Carrier Screen
|
Professional
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$1,285.35 |
| Rate for Payer: Aetna Commercial |
$1,285.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,163.58
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,285.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$676.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,231.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$1,082.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.35
|
| Rate for Payer: Quartz Beloit One Network |
$595.32
|
| Rate for Payer: Quartz Commercial |
$771.21
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$541.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: WEA Trust Commercial |
$744.15
|
| Rate for Payer: WPS Commercial |
$602.80
|
|
|
SMA Diagnostic Test
|
Facility
OP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$4,656.00 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$513.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.42
|
| Rate for Payer: Anthem Medicaid |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$509.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Managed Health Services Medicaid |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$205.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$137.00
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$756.60
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$4,656.00
|
| Rate for Payer: United Healthcare Medicaid |
$137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: United Healthcare PPO |
$873.00
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: Wellcare Medicare |
$137.00
|
| Rate for Payer: WMAP Medicaid |
$137.00
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
SMA Diagnostic Test
|
Facility
IP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$570.36 |
| Max. Negotiated Rate |
$1,070.88 |
| Rate for Payer: Aetna Commercial |
$1,047.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.92
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,070.88
|
| Rate for Payer: Health EOS Commercial |
$1,035.96
|
| Rate for Payer: HFN Commercial |
$1,070.88
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: NAPHCARE Commercial |
$698.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.88
|
| Rate for Payer: Quartz Beloit One Network |
$570.36
|
| Rate for Payer: Quartz Commercial |
$698.40
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$862.17
|
|
|
SMA Diagnostic Test
|
Professional
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$1,105.80 |
| Rate for Payer: Aetna Commercial |
$1,105.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.04
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,105.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$582.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$1,059.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$931.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,105.80
|
| Rate for Payer: Quartz Beloit One Network |
$512.16
|
| Rate for Payer: Quartz Commercial |
$663.48
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$541.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: WEA Trust Commercial |
$640.20
|
| Rate for Payer: WPS Commercial |
$602.80
|
|
|
Small black foam
|
Facility
IP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$314.58 |
| Max. Negotiated Rate |
$590.64 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$385.20
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
|
Small black foam
|
Facility
OP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$179.76 |
| Max. Negotiated Rate |
$2,568.00 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.12
|
| Rate for Payer: Aetna Managed Medicare |
$179.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$417.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$321.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$308.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$359.26
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$481.50
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$417.30
|
| Rate for Payer: Quartz Medicare Advantage |
$385.20
|
| Rate for Payer: The Alliance Commercial |
$2,568.00
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
|
SMALL BOWEL RESECTION
|
Facility
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
SMALL BOWEL RESECTION
|
Facility
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Facility
IP
|
$493.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$241.57 |
| Max. Negotiated Rate |
$453.56 |
| Rate for Payer: Aetna Commercial |
$443.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.29
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$453.56
|
| Rate for Payer: Health EOS Commercial |
$438.77
|
| Rate for Payer: HFN Commercial |
$453.56
|
| Rate for Payer: Multiplan Commercial |
$394.40
|
| Rate for Payer: NAPHCARE Commercial |
$295.80
|
| Rate for Payer: Preferred Network Access Commercial |
$453.56
|
| Rate for Payer: Quartz Beloit One Network |
$241.57
|
| Rate for Payer: Quartz Commercial |
$295.80
|
| Rate for Payer: WEA Trust Commercial |
$271.15
|
| Rate for Payer: WPS Commercial |
$365.17
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Facility
OP
|
$493.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$145.52 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$443.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$423.98
|
| Rate for Payer: Aetna Managed Medicare |
$292.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$320.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$246.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$236.64
|
| Rate for Payer: Anthem Medicare Advantage |
$292.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$292.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$292.75
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$453.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$292.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$292.75
|
| Rate for Payer: Health EOS Commercial |
$438.77
|
| Rate for Payer: HFN Commercial |
$453.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,089.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$292.75
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$292.75
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$292.75
|
| Rate for Payer: Multiplan Commercial |
$394.40
|
| Rate for Payer: NAPHCARE Commercial |
$439.12
|
| Rate for Payer: Preferred Network Access Commercial |
$453.56
|
| Rate for Payer: Quartz Beloit One Network |
$241.57
|
| Rate for Payer: Quartz Commercial |
$320.45
|
| Rate for Payer: Quartz Medicare Advantage |
$292.75
|
| Rate for Payer: The Alliance Commercial |
$145.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$292.75
|
| Rate for Payer: WEA Trust Commercial |
$271.15
|
| Rate for Payer: Wellcare Medicare |
$292.75
|
| Rate for Payer: WPS Commercial |
$365.17
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Professional
|
$82.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$149.40 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Medicare Advantage |
$33.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.20
|
| Rate for Payer: Health EOS Commercial |
$74.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$119.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.20
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: Preferred Network Access Commercial |
$77.90
|
| Rate for Payer: Quartz Beloit One Network |
$36.08
|
| Rate for Payer: Quartz Commercial |
$46.74
|
| Rate for Payer: Quartz Medicare Advantage |
$33.20
|
| Rate for Payer: The Alliance Commercial |
$141.10
|
| Rate for Payer: United Healthcare Medicaid |
$38.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$149.40
|
|
|
Small joint or bursa w/ultrasound guidance 20604
|
Professional
|
$1,424.00
|
|
|
Service Code
|
CPT 20604
|
| Hospital Charge Code |
4500691
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.14 |
| Max. Negotiated Rate |
$1,352.80 |
| Rate for Payer: Aetna Commercial |
$1,352.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,224.64
|
| Rate for Payer: Aetna Managed Medicare |
$43.14
|
| Rate for Payer: Anthem Medicare Advantage |
$43.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.14
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cigna Commercial |
$1,352.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$712.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.14
|
| Rate for Payer: Health EOS Commercial |
$1,295.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.14
|
| Rate for Payer: Multiplan Commercial |
$1,139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,352.80
|
| Rate for Payer: Quartz Beloit One Network |
$626.56
|
| Rate for Payer: Quartz Commercial |
$811.68
|
| Rate for Payer: Quartz Medicare Advantage |
$43.14
|
| Rate for Payer: The Alliance Commercial |
$183.34
|
| Rate for Payer: United Healthcare Medicaid |
$55.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.14
|
| Rate for Payer: WEA Trust Commercial |
$783.20
|
| Rate for Payer: WPS Commercial |
$194.13
|
|
|
Small joint w/ultrasound guidance 2060450
|
Professional
|
$2,845.00
|
|
|
Service Code
|
CPT 20604 50
|
| Hospital Charge Code |
5388753
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$2,702.75 |
| Rate for Payer: Aetna Commercial |
$2,702.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,446.70
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,702.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,422.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,707.00
|
| Rate for Payer: Health EOS Commercial |
$2,588.95
|
| Rate for Payer: Multiplan Commercial |
$2,276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,702.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.80
|
| Rate for Payer: Quartz Commercial |
$1,621.65
|
| Rate for Payer: The Alliance Commercial |
$1,422.50
|
| Rate for Payer: United Healthcare Medicaid |
$55.62
|
| Rate for Payer: WEA Trust Commercial |
$1,564.75
|
| Rate for Payer: WPS Commercial |
$2,107.29
|
|
|
Small white foam
|
Facility
IP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| 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
|
|
|
Small white foam
|
Facility
OP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.48 |
| Max. Negotiated Rate |
$764.00 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$53.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$95.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.68
|
| 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: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.25
|
| 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 |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$114.60
|
| Rate for Payer: The Alliance Commercial |
$764.00
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
SM Antibody
|
Professional
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$70.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$78.89
|
|
|
SM Antibody
|
Facility
OP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$976.00 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Anthem Medicaid |
$18.53
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Managed Health Services Medicaid |
$19.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.90
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.53
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$976.00
|
| Rate for Payer: United Healthcare Medicaid |
$18.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Healthcare PPO |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: WMAP Medicaid |
$18.53
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SM Antibody
|
Facility
IP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SMART NAIL 1.5x16MM
|
Facility
OP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$705.04 |
| Max. Negotiated Rate |
$10,072.00 |
| Rate for Payer: Aetna Commercial |
$2,266.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,165.48
|
| Rate for Payer: Aetna Managed Medicare |
$705.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,636.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,208.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,334.54
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,316.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,409.07
|
| Rate for Payer: Health EOS Commercial |
$2,241.02
|
| Rate for Payer: HFN Commercial |
$2,316.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,888.50
|
| Rate for Payer: Multiplan Commercial |
$2,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,510.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,316.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,233.82
|
| Rate for Payer: Quartz Commercial |
$1,636.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,510.80
|
| Rate for Payer: The Alliance Commercial |
$10,072.00
|
| Rate for Payer: WEA Trust Commercial |
$1,384.90
|
| Rate for Payer: WPS Commercial |
$1,865.08
|
|
|
SMART NAIL 1.5x16MM
|
Facility
IP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.82 |
| Max. Negotiated Rate |
$2,316.56 |
| Rate for Payer: Aetna Commercial |
$2,266.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,334.54
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,316.56
|
| Rate for Payer: Health EOS Commercial |
$2,241.02
|
| Rate for Payer: HFN Commercial |
$2,316.56
|
| Rate for Payer: Multiplan Commercial |
$2,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,510.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,316.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,233.82
|
| Rate for Payer: Quartz Commercial |
$1,510.80
|
| Rate for Payer: WEA Trust Commercial |
$1,384.90
|
| Rate for Payer: WPS Commercial |
$1,865.08
|
|
|
SMART TOE 19MM 10DEG STOA-19P
|
Facility
IP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.38 |
| Max. Negotiated Rate |
$5,853.04 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$3,817.20
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
|
SMART TOE 19MM 10DEG STOA-19P
|
Facility
OP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,781.36 |
| Max. Negotiated Rate |
$5,853.04 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,781.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,135.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,181.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,053.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,560.18
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,771.50
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$4,135.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,817.20
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
