|
SMA Carrier Screen
|
Professional
|
Both
|
$1,353.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
3805565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.48 |
| Max. Negotiated Rate |
$1,336.76 |
| Rate for Payer: Aetna Commercial |
$1,336.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.12
|
| Rate for Payer: Aetna Managed Medicare |
$142.48
|
| Rate for Payer: Anthem Medicare Advantage |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$142.48
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cash Price |
$405.90
|
| Rate for Payer: Cigna Commercial |
$1,336.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$703.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.48
|
| Rate for Payer: Health EOS Commercial |
$1,280.48
|
| Rate for Payer: HFN Commercial |
$1,336.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$502.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$502.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$142.48
|
| Rate for Payer: Multiplan Commercial |
$1,125.70
|
| Rate for Payer: NAPHCARE Commercial |
$213.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,336.76
|
| Rate for Payer: Quartz Beloit One Network |
$619.13
|
| Rate for Payer: Quartz Commercial |
$802.06
|
| Rate for Payer: Quartz Medicare Advantage |
$142.48
|
| Rate for Payer: The Alliance Commercial |
$562.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.48
|
| Rate for Payer: WEA Trust Commercial |
$773.92
|
| Rate for Payer: WPS Commercial |
$626.91
|
|
|
SMA Diagnostic Test
|
Facility
|
OP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.48 |
| Max. Negotiated Rate |
$1,113.72 |
| Rate for Payer: Aetna Commercial |
$1,089.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.08
|
| Rate for Payer: Aetna Managed Medicare |
$142.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$534.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$236.52
|
| Rate for Payer: Anthem Medicare Advantage |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$142.48
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,113.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$142.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$677.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$142.48
|
| Rate for Payer: Health EOS Commercial |
$1,077.40
|
| Rate for Payer: HFN Commercial |
$1,113.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$530.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$142.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$142.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$142.48
|
| Rate for Payer: Multiplan Commercial |
$968.45
|
| Rate for Payer: NAPHCARE Commercial |
$213.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,113.72
|
| Rate for Payer: Quartz Beloit One Network |
$593.17
|
| Rate for Payer: Quartz Commercial |
$786.86
|
| Rate for Payer: Quartz Medicare Advantage |
$142.48
|
| Rate for Payer: The Alliance Commercial |
$569.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.48
|
| Rate for Payer: United Healthcare PPO |
$907.92
|
| Rate for Payer: WEA Trust Commercial |
$665.81
|
| Rate for Payer: Wellcare Medicare |
$142.48
|
| Rate for Payer: WPS Commercial |
$896.63
|
|
|
SMA Diagnostic Test
|
Facility
|
IP
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$593.17 |
| Max. Negotiated Rate |
$1,113.72 |
| Rate for Payer: Aetna Commercial |
$1,089.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.60
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,113.72
|
| Rate for Payer: Health EOS Commercial |
$1,077.40
|
| Rate for Payer: HFN Commercial |
$1,113.72
|
| Rate for Payer: Multiplan Commercial |
$968.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,113.72
|
| Rate for Payer: Quartz Beloit One Network |
$593.17
|
| Rate for Payer: Quartz Commercial |
$726.34
|
| Rate for Payer: WEA Trust Commercial |
$665.81
|
| Rate for Payer: WPS Commercial |
$896.63
|
|
|
SMA Diagnostic Test
|
Professional
|
Both
|
$1,164.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4622663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.48 |
| Max. Negotiated Rate |
$1,150.03 |
| Rate for Payer: Aetna Commercial |
$1,150.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.08
|
| Rate for Payer: Aetna Managed Medicare |
$142.48
|
| Rate for Payer: Anthem Medicare Advantage |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$142.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$142.48
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cash Price |
$349.20
|
| Rate for Payer: Cigna Commercial |
$1,150.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$605.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.48
|
| Rate for Payer: Health EOS Commercial |
$1,101.61
|
| Rate for Payer: HFN Commercial |
$1,150.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$502.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$502.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$142.48
|
| Rate for Payer: Multiplan Commercial |
$968.45
|
| Rate for Payer: NAPHCARE Commercial |
$213.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,150.03
|
| Rate for Payer: Quartz Beloit One Network |
$532.65
|
| Rate for Payer: Quartz Commercial |
$690.02
|
| Rate for Payer: Quartz Medicare Advantage |
$142.48
|
| Rate for Payer: The Alliance Commercial |
$562.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.48
|
| Rate for Payer: WEA Trust Commercial |
$665.81
|
| Rate for Payer: WPS Commercial |
$626.91
|
|
|
Small black foam
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$327.16 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$400.61
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
Small black foam
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
3006911
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$186.95 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Aetna Managed Medicare |
$186.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$433.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$333.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.64
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$500.76
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: NAPHCARE Commercial |
$400.61
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$433.99
|
| Rate for Payer: Quartz Medicare Advantage |
$400.61
|
| Rate for Payer: The Alliance Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
SMALL BOWEL RESECTION
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
SMALL BOWEL RESECTION
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,298.75 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,298.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,014.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,478.80
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.04
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.04
|
| Rate for Payer: The Alliance Commercial |
$2,319.20
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
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 |
$251.23 |
| Max. Negotiated Rate |
$471.70 |
| Rate for Payer: Aetna Commercial |
$461.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$440.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$271.74
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$471.70
|
| Rate for Payer: Health EOS Commercial |
$456.32
|
| Rate for Payer: HFN Commercial |
$471.70
|
| Rate for Payer: Multiplan Commercial |
$410.18
|
| Rate for Payer: Preferred Network Access Commercial |
$471.70
|
| Rate for Payer: Quartz Beloit One Network |
$251.23
|
| Rate for Payer: Quartz Commercial |
$307.63
|
| Rate for Payer: WEA Trust Commercial |
$282.00
|
| Rate for Payer: WPS Commercial |
$379.76
|
|
|
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 |
$246.11 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$461.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$440.94
|
| Rate for Payer: Aetna Managed Medicare |
$323.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$333.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$256.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.11
|
| Rate for Payer: Anthem Medicare Advantage |
$323.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$271.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$323.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$323.03
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$471.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$323.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$323.03
|
| Rate for Payer: Health EOS Commercial |
$456.32
|
| Rate for Payer: HFN Commercial |
$471.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,201.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$323.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$323.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$323.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$323.03
|
| Rate for Payer: Multiplan Commercial |
$410.18
|
| Rate for Payer: NAPHCARE Commercial |
$484.55
|
| Rate for Payer: Preferred Network Access Commercial |
$471.70
|
| Rate for Payer: Quartz Beloit One Network |
$251.23
|
| Rate for Payer: Quartz Commercial |
$333.27
|
| Rate for Payer: Quartz Medicare Advantage |
$323.03
|
| Rate for Payer: The Alliance Commercial |
$1,292.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$323.03
|
| Rate for Payer: WEA Trust Commercial |
$282.00
|
| Rate for Payer: Wellcare Medicare |
$323.03
|
| Rate for Payer: WPS Commercial |
$379.76
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$136.84 |
| Rate for Payer: Aetna Commercial |
$81.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$30.41
|
| Rate for Payer: Anthem Medicare Advantage |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.41
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$81.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.41
|
| Rate for Payer: Health EOS Commercial |
$77.60
|
| Rate for Payer: HFN Commercial |
$81.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$124.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$45.61
|
| Rate for Payer: Preferred Network Access Commercial |
$81.02
|
| Rate for Payer: Quartz Beloit One Network |
$37.52
|
| Rate for Payer: Quartz Commercial |
$48.61
|
| Rate for Payer: Quartz Medicare Advantage |
$30.41
|
| Rate for Payer: The Alliance Commercial |
$129.24
|
| Rate for Payer: United Healthcare Medicaid |
$40.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.41
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$136.84
|
|
|
Small joint or bursa w/ultrasound guidance 20604
|
Professional
|
Both
|
$1,424.00
|
|
|
Service Code
|
CPT 20604
|
| Hospital Charge Code |
4500691
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.39 |
| Max. Negotiated Rate |
$1,406.91 |
| Rate for Payer: Aetna Commercial |
$1,406.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,273.63
|
| Rate for Payer: Aetna Managed Medicare |
$38.39
|
| Rate for Payer: Anthem Medicare Advantage |
$38.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.39
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cigna Commercial |
$1,406.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.39
|
| Rate for Payer: Health EOS Commercial |
$1,347.67
|
| Rate for Payer: HFN Commercial |
$1,406.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.39
|
| Rate for Payer: Multiplan Commercial |
$1,184.77
|
| Rate for Payer: NAPHCARE Commercial |
$57.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,406.91
|
| Rate for Payer: Quartz Beloit One Network |
$651.62
|
| Rate for Payer: Quartz Commercial |
$844.15
|
| Rate for Payer: Quartz Medicare Advantage |
$38.39
|
| Rate for Payer: The Alliance Commercial |
$163.14
|
| Rate for Payer: United Healthcare Medicaid |
$57.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.39
|
| Rate for Payer: WEA Trust Commercial |
$814.53
|
| Rate for Payer: WPS Commercial |
$172.74
|
|
|
Small joint w/ultrasound guidance 2060450
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
CPT 20604 50
|
| Hospital Charge Code |
5388753
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.84 |
| Max. Negotiated Rate |
$2,810.86 |
| Rate for Payer: Aetna Commercial |
$2,810.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,544.57
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,810.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,775.28
|
| Rate for Payer: Health EOS Commercial |
$2,692.51
|
| Rate for Payer: HFN Commercial |
$2,810.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.24
|
| Rate for Payer: Multiplan Commercial |
$2,367.04
|
| Rate for Payer: Preferred Network Access Commercial |
$2,810.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,301.87
|
| Rate for Payer: Quartz Commercial |
$1,686.52
|
| Rate for Payer: The Alliance Commercial |
$1,479.40
|
| Rate for Payer: United Healthcare Medicaid |
$57.84
|
| Rate for Payer: WEA Trust Commercial |
$1,627.34
|
| Rate for Payer: WPS Commercial |
$2,191.50
|
|
|
Small white foam
|
Facility
|
IP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.33 |
| Max. Negotiated Rate |
$182.75 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$119.18
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
Small white foam
|
Facility
|
OP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$182.75 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Aetna Managed Medicare |
$55.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.16
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.98
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: NAPHCARE Commercial |
$119.18
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$129.12
|
| Rate for Payer: Quartz Medicare Advantage |
$119.18
|
| Rate for Payer: The Alliance Commercial |
$99.32
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
SM Antibody
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$152.26
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
SM Antibody
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$18.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Anthem Medicare Advantage |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.65
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.65
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$164.94
|
| Rate for Payer: Quartz Medicare Advantage |
$18.65
|
| Rate for Payer: The Alliance Commercial |
$74.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.65
|
| Rate for Payer: United Healthcare PPO |
$190.32
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: Wellcare Medicare |
$18.65
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
SM Antibody
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$241.07 |
| Rate for Payer: Aetna Commercial |
$241.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$18.65
|
| Rate for Payer: Anthem Medicare Advantage |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.65
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$241.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$126.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$230.92
|
| Rate for Payer: HFN Commercial |
$241.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.65
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$241.07
|
| Rate for Payer: Quartz Beloit One Network |
$111.65
|
| Rate for Payer: Quartz Commercial |
$144.64
|
| Rate for Payer: Quartz Medicare Advantage |
$18.65
|
| Rate for Payer: The Alliance Commercial |
$73.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.65
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$82.05
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
IP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,283.17 |
| Max. Negotiated Rate |
$2,409.22 |
| Rate for Payer: Aetna Commercial |
$2,356.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,252.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.92
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,409.22
|
| Rate for Payer: Health EOS Commercial |
$2,330.66
|
| Rate for Payer: HFN Commercial |
$2,409.22
|
| Rate for Payer: Multiplan Commercial |
$2,094.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,409.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.17
|
| Rate for Payer: Quartz Commercial |
$1,571.23
|
| Rate for Payer: WEA Trust Commercial |
$1,440.30
|
| Rate for Payer: WPS Commercial |
$1,939.62
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
OP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$733.24 |
| Max. Negotiated Rate |
$2,409.22 |
| Rate for Payer: Aetna Commercial |
$2,356.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,252.10
|
| Rate for Payer: Aetna Managed Medicare |
$733.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,702.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,309.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,256.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.92
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,409.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,465.48
|
| Rate for Payer: Health EOS Commercial |
$2,330.66
|
| Rate for Payer: HFN Commercial |
$2,409.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,964.04
|
| Rate for Payer: Multiplan Commercial |
$2,094.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,571.23
|
| Rate for Payer: Preferred Network Access Commercial |
$2,409.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.17
|
| Rate for Payer: Quartz Commercial |
$1,702.17
|
| Rate for Payer: Quartz Medicare Advantage |
$1,571.23
|
| Rate for Payer: The Alliance Commercial |
$1,309.36
|
| Rate for Payer: WEA Trust Commercial |
$1,440.30
|
| Rate for Payer: WPS Commercial |
$1,939.62
|
|
|
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 |
$1,852.61 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,852.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,300.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,308.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,175.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,702.68
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,962.36
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: NAPHCARE Commercial |
$3,969.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$4,300.71
|
| Rate for Payer: Quartz Medicare Advantage |
$3,969.89
|
| Rate for Payer: The Alliance Commercial |
$3,308.24
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
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 |
$3,242.08 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$3,969.89
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
SMARTWIRE II XT (VOLCANO) 185cm #6603
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,774.77 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,397.68
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
SMARTWIRE II XT (VOLCANO) 185cm #6603
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,585.58 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,585.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,680.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,831.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,718.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,168.99
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,247.10
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.68
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,680.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,397.68
|
| Rate for Payer: The Alliance Commercial |
$2,831.40
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
SMARTWIRE II XT (VOLCANO) 300cm #6613
|
Facility
|
IP
|
$5,035.00
|
|
| Hospital Charge Code |
2973639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,565.84 |
| Max. Negotiated Rate |
$4,817.49 |
| Rate for Payer: Aetna Commercial |
$4,712.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,503.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,775.29
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,817.49
|
| Rate for Payer: Health EOS Commercial |
$4,660.40
|
| Rate for Payer: HFN Commercial |
$4,817.49
|
| Rate for Payer: Multiplan Commercial |
$4,189.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,817.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,565.84
|
| Rate for Payer: Quartz Commercial |
$3,141.84
|
| Rate for Payer: WEA Trust Commercial |
$2,880.02
|
| Rate for Payer: WPS Commercial |
$3,878.46
|
|
