|
U Ethyl Glucuronide / 90418
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80321
|
| Hospital Charge Code |
3530179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
UGT1A1 Gene Polymorphism (TA Repeat)
|
Professional
|
Both
|
$716.00
|
|
|
Service Code
|
CPT 81350
|
| Hospital Charge Code |
4392920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$315.04 |
| Max. Negotiated Rate |
$826.02 |
| Rate for Payer: Aetna Commercial |
$680.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$615.76
|
| Rate for Payer: Cash Price |
$214.80
|
| Rate for Payer: Cash Price |
$214.80
|
| Rate for Payer: Cigna Commercial |
$680.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$358.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$429.60
|
| Rate for Payer: Health EOS Commercial |
$651.56
|
| Rate for Payer: HFN Commercial |
$680.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$826.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$826.02
|
| Rate for Payer: Multiplan Commercial |
$572.80
|
| Rate for Payer: Preferred Network Access Commercial |
$680.20
|
| Rate for Payer: Quartz Beloit One Network |
$315.04
|
| Rate for Payer: Quartz Commercial |
$408.12
|
| Rate for Payer: The Alliance Commercial |
$358.00
|
| Rate for Payer: WEA Trust Commercial |
$393.80
|
| Rate for Payer: WPS Commercial |
$530.34
|
|
|
UGT1A1 Gene Polymorphism (TA Repeat)
|
Facility
|
IP
|
$716.00
|
|
|
Service Code
|
CPT 81350
|
| Hospital Charge Code |
4392920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$350.84 |
| Max. Negotiated Rate |
$658.72 |
| Rate for Payer: Aetna Commercial |
$644.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$615.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$379.48
|
| Rate for Payer: Cash Price |
$214.80
|
| Rate for Payer: Cigna Commercial |
$658.72
|
| Rate for Payer: Health EOS Commercial |
$637.24
|
| Rate for Payer: HFN Commercial |
$658.72
|
| Rate for Payer: Multiplan Commercial |
$572.80
|
| Rate for Payer: NAPHCARE Commercial |
$429.60
|
| Rate for Payer: Preferred Network Access Commercial |
$658.72
|
| Rate for Payer: Quartz Beloit One Network |
$350.84
|
| Rate for Payer: Quartz Commercial |
$429.60
|
| Rate for Payer: WEA Trust Commercial |
$393.80
|
| Rate for Payer: WPS Commercial |
$530.34
|
|
|
UGT1A1 Gene Polymorphism (TA Repeat)
|
Facility
|
OP
|
$716.00
|
|
|
Service Code
|
CPT 81350
|
| Hospital Charge Code |
4392920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$644.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$615.76
|
| Rate for Payer: Aetna Managed Medicare |
$234.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$877.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$409.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$388.44
|
| Rate for Payer: Anthem Medicare Advantage |
$234.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$379.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$234.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$234.00
|
| Rate for Payer: Cash Price |
$214.80
|
| Rate for Payer: Cash Price |
$214.80
|
| Rate for Payer: Cigna Commercial |
$658.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$234.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$400.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$234.00
|
| Rate for Payer: Health EOS Commercial |
$637.24
|
| Rate for Payer: HFN Commercial |
$658.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$870.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$234.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$234.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$234.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$234.00
|
| Rate for Payer: Multiplan Commercial |
$572.80
|
| Rate for Payer: NAPHCARE Commercial |
$351.00
|
| Rate for Payer: Preferred Network Access Commercial |
$658.72
|
| Rate for Payer: Quartz Beloit One Network |
$350.84
|
| Rate for Payer: Quartz Commercial |
$465.40
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$234.00
|
| Rate for Payer: United Healthcare PPO |
$537.00
|
| Rate for Payer: WEA Trust Commercial |
$393.80
|
| Rate for Payer: Wellcare Medicare |
$234.00
|
| Rate for Payer: WPS Commercial |
$530.34
|
|
|
ULNA INTRAMEDULLARY RODDING
|
Facility
|
IP
|
$4,560.00
|
|
| Hospital Charge Code |
2960153
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,234.40 |
| Max. Negotiated Rate |
$4,195.20 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
ULNA INTRAMEDULLARY RODDING
|
Facility
|
OP
|
$4,560.00
|
|
| Hospital Charge Code |
2960153
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$18,240.00 |
| Rate for Payer: Aetna Commercial |
$4,104.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,921.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,276.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,964.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,280.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,188.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,416.80
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Cigna Commercial |
$4,195.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,551.78
|
| Rate for Payer: Health EOS Commercial |
$4,058.40
|
| Rate for Payer: HFN Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,420.00
|
| Rate for Payer: Multiplan Commercial |
$3,648.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,736.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,195.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,234.40
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,736.00
|
| Rate for Payer: The Alliance Commercial |
$18,240.00
|
| Rate for Payer: WEA Trust Commercial |
$2,508.00
|
| Rate for Payer: WPS Commercial |
$3,377.59
|
|
|
ULNAR COLATERAL LIGAMENT RECONSTRUCTION
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960202
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
ULNAR COLATERAL LIGAMENT RECONSTRUCTION
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960202
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
Ulnar Gutter Splint Custom
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989889
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$1,144.00 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$237.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$1,144.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Ulnar Gutter Splint Custom
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS L3906
|
| Hospital Charge Code |
2989889
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
ULNAR NERVE RELEASE
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2960466
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
ULNAR NERVE RELEASE
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2960466
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
ULTRABAG 2.5L 4.25% #5B9898P
|
Facility
|
OP
|
$184.00
|
|
| Hospital Charge Code |
2971654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
ULTRABAG 2.5L 4.25% #5B9898P
|
Facility
|
IP
|
$184.00
|
|
| Hospital Charge Code |
2971654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
ULTRASLING II LG ARM 11630007
|
Facility
|
OP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965895
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$4,172.00 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Aetna Managed Medicare |
$292.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.66
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$782.25
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$677.95
|
| Rate for Payer: Quartz Medicare Advantage |
$625.80
|
| Rate for Payer: The Alliance Commercial |
$4,172.00
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
ULTRASLING II LG ARM 11630007
|
Facility
|
IP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965895
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$511.07 |
| Max. Negotiated Rate |
$959.56 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$625.80
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
ULTRASLING II MED ARM 11630006
|
Facility
|
OP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965896
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$4,172.00 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Aetna Managed Medicare |
$292.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.66
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$782.25
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$677.95
|
| Rate for Payer: Quartz Medicare Advantage |
$625.80
|
| Rate for Payer: The Alliance Commercial |
$4,172.00
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
ULTRASLING II MED ARM 11630006
|
Facility
|
IP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965896
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$511.07 |
| Max. Negotiated Rate |
$959.56 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$625.80
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
ULTRASLING II SM ARM 11630005
|
Facility
|
OP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965897
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$4,172.00 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Aetna Managed Medicare |
$292.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.66
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$782.25
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$677.95
|
| Rate for Payer: Quartz Medicare Advantage |
$625.80
|
| Rate for Payer: The Alliance Commercial |
$4,172.00
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
ULTRASLING II SM ARM 11630005
|
Facility
|
IP
|
$1,043.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
2965897
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$511.07 |
| Max. Negotiated Rate |
$959.56 |
| Rate for Payer: Aetna Commercial |
$938.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$896.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$552.79
|
| Rate for Payer: Cash Price |
$312.90
|
| Rate for Payer: Cigna Commercial |
$959.56
|
| Rate for Payer: Health EOS Commercial |
$928.27
|
| Rate for Payer: HFN Commercial |
$959.56
|
| Rate for Payer: Multiplan Commercial |
$834.40
|
| Rate for Payer: NAPHCARE Commercial |
$625.80
|
| Rate for Payer: Preferred Network Access Commercial |
$959.56
|
| Rate for Payer: Quartz Beloit One Network |
$511.07
|
| Rate for Payer: Quartz Commercial |
$625.80
|
| Rate for Payer: WEA Trust Commercial |
$573.65
|
| Rate for Payer: WPS Commercial |
$772.55
|
|
|
Ultrasonic guidance for needle
placement 7694226
|
Professional
|
Both
|
$376.00
|
|
|
Service Code
|
CPT 76942 26
|
| Hospital Charge Code |
3121602
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$106.04 |
| Max. Negotiated Rate |
$357.20 |
| Rate for Payer: Aetna Commercial |
$357.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$323.36
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cigna Commercial |
$357.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$188.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.60
|
| Rate for Payer: Health EOS Commercial |
$342.16
|
| Rate for Payer: HFN Commercial |
$357.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.04
|
| Rate for Payer: Multiplan Commercial |
$300.80
|
| Rate for Payer: Preferred Network Access Commercial |
$357.20
|
| Rate for Payer: Quartz Beloit One Network |
$165.44
|
| Rate for Payer: Quartz Commercial |
$214.32
|
| Rate for Payer: The Alliance Commercial |
$188.00
|
| Rate for Payer: WEA Trust Commercial |
$206.80
|
| Rate for Payer: WPS Commercial |
$278.50
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC
|
Facility
|
IP
|
$118,904.00
|
|
|
Service Code
|
MSDRG 278
|
| Min. Negotiated Rate |
$42,771.38 |
| Max. Negotiated Rate |
$118,904.00 |
| Rate for Payer: Aetna Managed Medicare |
$42,771.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93,570.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71,721.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68,139.88
|
| Rate for Payer: Anthem Medicare Advantage |
$42,771.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42,771.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42,771.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$42,771.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75,641.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$42,771.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86,977.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42,771.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42,771.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$42,771.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$42,771.38
|
| Rate for Payer: NAPHCARE Commercial |
$64,157.07
|
| Rate for Payer: Quartz Medicare Advantage |
$42,771.38
|
| Rate for Payer: The Alliance Commercial |
$118,904.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42,771.38
|
| Rate for Payer: United Healthcare PPO |
$67,713.33
|
| Rate for Payer: Wellcare Medicare |
$42,771.38
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC
|
Facility
|
IP
|
$85,411.00
|
|
|
Service Code
|
MSDRG 279
|
| Min. Negotiated Rate |
$30,723.55 |
| Max. Negotiated Rate |
$85,411.00 |
| Rate for Payer: Aetna Managed Medicare |
$30,723.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67,136.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51,459.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48,889.60
|
| Rate for Payer: Anthem Medicare Advantage |
$30,723.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,723.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,723.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,723.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54,271.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,723.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62,411.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,723.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,723.55
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,723.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,723.55
|
| Rate for Payer: NAPHCARE Commercial |
$46,085.32
|
| Rate for Payer: Quartz Medicare Advantage |
$30,723.55
|
| Rate for Payer: The Alliance Commercial |
$85,411.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,723.55
|
| Rate for Payer: United Healthcare PPO |
$48,588.31
|
| Rate for Payer: Wellcare Medicare |
$30,723.55
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM
|
Facility
|
IP
|
$82,072.00
|
|
|
Service Code
|
MSDRG 173
|
| Min. Negotiated Rate |
$29,522.39 |
| Max. Negotiated Rate |
$82,072.00 |
| Rate for Payer: Aetna Managed Medicare |
$29,522.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64,618.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49,529.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47,056.24
|
| Rate for Payer: Anthem Medicare Advantage |
$29,522.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29,522.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29,522.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29,522.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52,236.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29,522.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59,962.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29,522.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29,522.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29,522.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29,522.39
|
| Rate for Payer: NAPHCARE Commercial |
$44,283.58
|
| Rate for Payer: Quartz Medicare Advantage |
$29,522.39
|
| Rate for Payer: The Alliance Commercial |
$82,072.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29,522.39
|
| Rate for Payer: United Healthcare PPO |
$46,681.58
|
| Rate for Payer: Wellcare Medicare |
$29,522.39
|
|
|
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS IN OR
|
Facility
|
OP
|
$479.00
|
|
| Hospital Charge Code |
2962836
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$1,916.00 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$134.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.05
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$359.25
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$311.35
|
| Rate for Payer: Quartz Medicare Advantage |
$287.40
|
| Rate for Payer: The Alliance Commercial |
$1,916.00
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
