|
SWEA 99292 Critical care, evaluation and management of the critically ill or critically inj
|
Facility
OP
|
$566.00
|
|
|
Service Code
|
CPT 99292
|
| Hospital Charge Code |
3147613
|
|
Hospital Revenue Code
|
456
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$583.00 |
| Rate for Payer: Aetna Commercial |
$509.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$486.76
|
| Rate for Payer: Aetna Managed Medicare |
$158.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$583.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$410.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.98
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cigna Commercial |
$520.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.32
|
| Rate for Payer: Health EOS Commercial |
$503.74
|
| Rate for Payer: HFN Commercial |
$520.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$424.50
|
| Rate for Payer: Multiplan Commercial |
$452.80
|
| Rate for Payer: NAPHCARE Commercial |
$339.60
|
| Rate for Payer: Preferred Network Access Commercial |
$520.72
|
| Rate for Payer: Quartz Beloit One Network |
$277.34
|
| Rate for Payer: Quartz Commercial |
$367.90
|
| Rate for Payer: Quartz Medicare Advantage |
$339.60
|
| Rate for Payer: United Healthcare PPO |
$424.50
|
| Rate for Payer: WEA Trust Commercial |
$311.30
|
| Rate for Payer: WPS Commercial |
$419.24
|
|
|
SWELL SPOT DORSAL (SM) #SP-02-S
|
Facility
IP
|
$269.00
|
|
| Hospital Charge Code |
2970855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$161.40
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
SWELL SPOT DORSAL (SM) #SP-02-S
|
Facility
OP
|
$269.00
|
|
| Hospital Charge Code |
2970855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.32 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Aetna Managed Medicare |
$75.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.53
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.75
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$174.85
|
| Rate for Payer: Quartz Medicare Advantage |
$161.40
|
| Rate for Payer: The Alliance Commercial |
$1,076.00
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
SWELL SPOTS CURVED #5609-18-03
|
Facility
OP
|
$430.00
|
|
| Hospital Charge Code |
2971122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: Aetna Managed Medicare |
$120.40
|
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.63
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.50
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$258.00
|
| Rate for Payer: The Alliance Commercial |
$1,720.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
SWELL SPOTS CURVED #5609-18-03
|
Facility
IP
|
$430.00
|
|
| Hospital Charge Code |
2971122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
SWELL SPOTS DORSAL (SMALL) #5609-18-01
|
Facility
IP
|
$430.00
|
|
| Hospital Charge Code |
2971121
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.70 |
| Max. Negotiated Rate |
$395.60 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$258.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
SWELL SPOTS DORSAL (SMALL) #5609-18-01
|
Facility
OP
|
$430.00
|
|
| Hospital Charge Code |
2971121
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: Aetna Commercial |
$387.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$369.80
|
| Rate for Payer: Aetna Managed Medicare |
$120.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$279.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$227.90
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$395.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.63
|
| Rate for Payer: Health EOS Commercial |
$382.70
|
| Rate for Payer: HFN Commercial |
$395.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.50
|
| Rate for Payer: Multiplan Commercial |
$344.00
|
| Rate for Payer: NAPHCARE Commercial |
$258.00
|
| Rate for Payer: Preferred Network Access Commercial |
$395.60
|
| Rate for Payer: Quartz Beloit One Network |
$210.70
|
| Rate for Payer: Quartz Commercial |
$279.50
|
| Rate for Payer: Quartz Medicare Advantage |
$258.00
|
| Rate for Payer: The Alliance Commercial |
$1,720.00
|
| Rate for Payer: WEA Trust Commercial |
$236.50
|
| Rate for Payer: WPS Commercial |
$318.50
|
|
|
SWELL SPOTS KATINA (SMALL) #5609-18-04
|
Facility
IP
|
$476.00
|
|
| Hospital Charge Code |
2971283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$233.24 |
| Max. Negotiated Rate |
$437.92 |
| Rate for Payer: Aetna Commercial |
$428.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$252.28
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$437.92
|
| Rate for Payer: Health EOS Commercial |
$423.64
|
| Rate for Payer: HFN Commercial |
$437.92
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: NAPHCARE Commercial |
$285.60
|
| Rate for Payer: Preferred Network Access Commercial |
$437.92
|
| Rate for Payer: Quartz Beloit One Network |
$233.24
|
| Rate for Payer: Quartz Commercial |
$285.60
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
SWELL SPOTS KATINA (SMALL) #5609-18-04
|
Facility
OP
|
$476.00
|
|
| Hospital Charge Code |
2971283
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$1,904.00 |
| Rate for Payer: Aetna Commercial |
$428.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$409.36
|
| Rate for Payer: Aetna Managed Medicare |
$133.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$309.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$238.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$228.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$252.28
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$437.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$266.37
|
| Rate for Payer: Health EOS Commercial |
$423.64
|
| Rate for Payer: HFN Commercial |
$437.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$357.00
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: NAPHCARE Commercial |
$285.60
|
| Rate for Payer: Preferred Network Access Commercial |
$437.92
|
| Rate for Payer: Quartz Beloit One Network |
$233.24
|
| Rate for Payer: Quartz Commercial |
$309.40
|
| Rate for Payer: Quartz Medicare Advantage |
$285.60
|
| Rate for Payer: The Alliance Commercial |
$1,904.00
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
SWELL SPOTS PALMER (SM) #SP-03-S
|
Facility
OP
|
$269.00
|
|
| Hospital Charge Code |
2971025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.32 |
| Max. Negotiated Rate |
$1,076.00 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Aetna Managed Medicare |
$75.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.53
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.75
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$174.85
|
| Rate for Payer: Quartz Medicare Advantage |
$161.40
|
| Rate for Payer: The Alliance Commercial |
$1,076.00
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
SWELL SPOTS PALMER (SM) #SP-03-S
|
Facility
IP
|
$269.00
|
|
| Hospital Charge Code |
2971025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$161.40
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Professional
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$155.76 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Aetna Commercial |
$336.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$336.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$212.40
|
| Rate for Payer: Health EOS Commercial |
$322.14
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: Preferred Network Access Commercial |
$336.30
|
| Rate for Payer: Quartz Beloit One Network |
$155.76
|
| Rate for Payer: Quartz Commercial |
$201.78
|
| Rate for Payer: The Alliance Commercial |
$177.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Facility
OP
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.44
|
| Rate for Payer: Aetna Managed Medicare |
$99.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$177.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$169.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.10
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.50
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$230.10
|
| Rate for Payer: Quartz Medicare Advantage |
$212.40
|
| Rate for Payer: The Alliance Commercial |
$1,416.00
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
Syfovre (pegcetacoplan) Ophthalmic 15mg/0.1 mL
|
Facility
IP
|
$354.00
|
|
|
Service Code
|
HCPCS C9151
|
| Hospital Charge Code |
6219274
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.46 |
| Max. Negotiated Rate |
$325.68 |
| Rate for Payer: Aetna Commercial |
$318.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.62
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$325.68
|
| Rate for Payer: Health EOS Commercial |
$315.06
|
| Rate for Payer: HFN Commercial |
$325.68
|
| Rate for Payer: Multiplan Commercial |
$283.20
|
| Rate for Payer: NAPHCARE Commercial |
$212.40
|
| Rate for Payer: Preferred Network Access Commercial |
$325.68
|
| Rate for Payer: Quartz Beloit One Network |
$173.46
|
| Rate for Payer: Quartz Commercial |
$212.40
|
| Rate for Payer: WEA Trust Commercial |
$194.70
|
| Rate for Payer: WPS Commercial |
$262.21
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
IP
|
$23,277.00
|
|
|
Service Code
|
MS-DRG 312
|
| Min. Negotiated Rate |
$8,373.17 |
| Max. Negotiated Rate |
$23,277.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,373.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,042.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,829.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,139.08
|
| Rate for Payer: Anthem Medicare Advantage |
$8,373.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,373.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,373.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,373.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,585.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,373.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,838.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,373.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,373.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,373.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,373.17
|
| Rate for Payer: NAPHCARE Commercial |
$12,559.76
|
| Rate for Payer: Quartz Medicare Advantage |
$8,373.17
|
| Rate for Payer: The Alliance Commercial |
$23,277.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,373.17
|
| Rate for Payer: United Healthcare PPO |
$13,108.79
|
| Rate for Payer: Wellcare Medicare |
$8,373.17
|
|
|
SYNDACTYLY
|
Facility
OP
|
$1,242.00
|
|
| Hospital Charge Code |
2960400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$347.76 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,068.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$807.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$621.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$596.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$695.02
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$931.50
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$807.30
|
| Rate for Payer: Quartz Medicare Advantage |
$745.20
|
| Rate for Payer: The Alliance Commercial |
$4,968.00
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
SYNDACTYLY
|
Facility
IP
|
$1,242.00
|
|
| Hospital Charge Code |
2960400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$608.58 |
| Max. Negotiated Rate |
$1,142.64 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$745.20
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
SYNDESMOSIS FIXATION DEVICE W # 5 SUTURE GRAVITY SYNCHFIX 86SYN005
|
Facility
IP
|
$6,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,246.25 |
| Max. Negotiated Rate |
$6,095.00 |
| Rate for Payer: Aetna Commercial |
$5,962.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,511.25
|
| Rate for Payer: Cash Price |
$1,987.50
|
| Rate for Payer: Cigna Commercial |
$6,095.00
|
| Rate for Payer: Health EOS Commercial |
$5,896.25
|
| Rate for Payer: HFN Commercial |
$6,095.00
|
| Rate for Payer: Multiplan Commercial |
$5,300.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,975.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,095.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,246.25
|
| Rate for Payer: Quartz Commercial |
$3,975.00
|
| Rate for Payer: WEA Trust Commercial |
$3,643.75
|
| Rate for Payer: WPS Commercial |
$4,907.14
|
|
|
SYNDESMOSIS FIXATION DEVICE W # 5 SUTURE GRAVITY SYNCHFIX 86SYN005
|
Facility
OP
|
$6,625.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,855.00 |
| Max. Negotiated Rate |
$6,095.00 |
| Rate for Payer: Aetna Commercial |
$5,962.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,697.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,855.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,306.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,312.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,180.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,511.25
|
| Rate for Payer: Cash Price |
$1,987.50
|
| Rate for Payer: Cigna Commercial |
$6,095.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,707.35
|
| Rate for Payer: Health EOS Commercial |
$5,896.25
|
| Rate for Payer: HFN Commercial |
$6,095.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,968.75
|
| Rate for Payer: Multiplan Commercial |
$5,300.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,975.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,095.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,246.25
|
| Rate for Payer: Quartz Commercial |
$4,306.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,975.00
|
| Rate for Payer: WEA Trust Commercial |
$3,643.75
|
| Rate for Payer: WPS Commercial |
$4,907.14
|
|
|
SYNOVECTOMY
|
Facility
OP
|
$1,242.00
|
|
| Hospital Charge Code |
2960401
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$347.76 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,068.12
|
| Rate for Payer: Aetna Managed Medicare |
$347.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$807.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$621.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$596.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$695.02
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$931.50
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$807.30
|
| Rate for Payer: Quartz Medicare Advantage |
$745.20
|
| Rate for Payer: The Alliance Commercial |
$4,968.00
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
SYNOVECTOMY
|
Facility
IP
|
$1,242.00
|
|
| Hospital Charge Code |
2960401
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$608.58 |
| Max. Negotiated Rate |
$1,142.64 |
| Rate for Payer: Aetna Commercial |
$1,117.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$658.26
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: Cigna Commercial |
$1,142.64
|
| Rate for Payer: Health EOS Commercial |
$1,105.38
|
| Rate for Payer: HFN Commercial |
$1,142.64
|
| Rate for Payer: Multiplan Commercial |
$993.60
|
| Rate for Payer: NAPHCARE Commercial |
$745.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,142.64
|
| Rate for Payer: Quartz Beloit One Network |
$608.58
|
| Rate for Payer: Quartz Commercial |
$745.20
|
| Rate for Payer: WEA Trust Commercial |
$683.10
|
| Rate for Payer: WPS Commercial |
$919.95
|
|
|
Synthesis Rate IgG CSF
|
Facility
IP
|
$274.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
2959003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$134.26 |
| Max. Negotiated Rate |
$252.08 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$164.40
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
Synthesis Rate IgG CSF
|
Professional
|
$274.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
2959003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$260.30 |
| Rate for Payer: Aetna Commercial |
$260.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Aetna Managed Medicare |
$17.20
|
| Rate for Payer: Anthem Medicare Advantage |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$260.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.20
|
| Rate for Payer: Health EOS Commercial |
$249.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.20
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: Preferred Network Access Commercial |
$260.30
|
| Rate for Payer: Quartz Beloit One Network |
$120.56
|
| Rate for Payer: Quartz Commercial |
$156.18
|
| Rate for Payer: Quartz Medicare Advantage |
$17.20
|
| Rate for Payer: The Alliance Commercial |
$67.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.20
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$75.68
|
|
|
Synthesis Rate IgG CSF
|
Facility
OP
|
$274.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
2959003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$1,096.00 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Aetna Managed Medicare |
$17.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.55
|
| Rate for Payer: Anthem Medicaid |
$17.77
|
| Rate for Payer: Anthem Medicare Advantage |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.77
|
| Rate for Payer: Dean Health Medicaid |
$17.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.20
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.20
|
| Rate for Payer: Managed Health Services Medicaid |
$18.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.20
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$25.80
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.77
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$178.10
|
| Rate for Payer: Quartz Medicare Advantage |
$17.20
|
| Rate for Payer: The Alliance Commercial |
$1,096.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.20
|
| Rate for Payer: United Healthcare PPO |
$205.50
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: Wellcare Medicare |
$17.20
|
| Rate for Payer: WMAP Medicaid |
$17.77
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
Synthetic Cannabinoids Screen w/ Confirmation, Urine
|
Facility
IP
|
$136.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5274914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.64 |
| Max. Negotiated Rate |
$125.12 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.08
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$125.12
|
| Rate for Payer: Health EOS Commercial |
$121.04
|
| Rate for Payer: HFN Commercial |
$125.12
|
| Rate for Payer: Multiplan Commercial |
$108.80
|
| Rate for Payer: NAPHCARE Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$125.12
|
| Rate for Payer: Quartz Beloit One Network |
$66.64
|
| Rate for Payer: Quartz Commercial |
$81.60
|
| Rate for Payer: WEA Trust Commercial |
$74.80
|
| Rate for Payer: WPS Commercial |
$100.74
|
|
