|
99281 - Level 1 - Lynx Visit Level
|
Facility
IP
|
$228.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
3031290
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
99282 - Level 2 - Lynx Visit Level
|
Facility
IP
|
$631.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
3031289
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$309.19 |
| Max. Negotiated Rate |
$580.52 |
| Rate for Payer: Aetna Commercial |
$567.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$334.43
|
| Rate for Payer: Cash Price |
$189.30
|
| Rate for Payer: Cigna Commercial |
$580.52
|
| Rate for Payer: Health EOS Commercial |
$561.59
|
| Rate for Payer: HFN Commercial |
$580.52
|
| Rate for Payer: Multiplan Commercial |
$504.80
|
| Rate for Payer: NAPHCARE Commercial |
$378.60
|
| Rate for Payer: Preferred Network Access Commercial |
$580.52
|
| Rate for Payer: Quartz Beloit One Network |
$309.19
|
| Rate for Payer: Quartz Commercial |
$378.60
|
| Rate for Payer: WEA Trust Commercial |
$347.05
|
| Rate for Payer: WPS Commercial |
$467.38
|
|
|
99282 - Level 2 - Lynx Visit Level
|
Facility
OP
|
$631.00
|
|
|
Service Code
|
CPT 99282
|
| Hospital Charge Code |
3031289
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$161.65 |
| Max. Negotiated Rate |
$641.00 |
| Rate for Payer: Aetna Commercial |
$567.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$542.66
|
| Rate for Payer: Aetna Managed Medicare |
$161.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$641.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$436.00
|
| Rate for Payer: Anthem Medicare Advantage |
$161.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$334.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$161.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$161.65
|
| Rate for Payer: Cash Price |
$189.30
|
| Rate for Payer: Cash Price |
$189.30
|
| Rate for Payer: Cash Price |
$189.30
|
| Rate for Payer: Cigna Commercial |
$580.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$161.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$353.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$161.65
|
| Rate for Payer: Health EOS Commercial |
$561.59
|
| Rate for Payer: HFN Commercial |
$580.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$601.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$161.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$161.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$161.65
|
| Rate for Payer: Multiplan Commercial |
$504.80
|
| Rate for Payer: NAPHCARE Commercial |
$242.48
|
| Rate for Payer: Preferred Network Access Commercial |
$580.52
|
| Rate for Payer: Quartz Beloit One Network |
$309.19
|
| Rate for Payer: Quartz Commercial |
$410.15
|
| Rate for Payer: Quartz Medicare Advantage |
$161.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$161.65
|
| Rate for Payer: United Healthcare PPO |
$526.00
|
| Rate for Payer: WEA Trust Commercial |
$347.05
|
| Rate for Payer: Wellcare Medicare |
$161.65
|
| Rate for Payer: WPS Commercial |
$467.38
|
|
|
99283 - Level 3 - Lynx Visit Level
|
Facility
OP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
3031288
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$282.01 |
| Max. Negotiated Rate |
$1,458.00 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$977.82
|
| Rate for Payer: Aetna Managed Medicare |
$282.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,458.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$873.00
|
| Rate for Payer: Anthem Medicare Advantage |
$282.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$282.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$282.01
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$282.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$282.01
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,049.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$282.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$282.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$282.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$282.01
|
| Rate for Payer: Multiplan Commercial |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$423.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$739.05
|
| Rate for Payer: Quartz Medicare Advantage |
$282.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$282.01
|
| Rate for Payer: United Healthcare PPO |
$1,217.00
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: Wellcare Medicare |
$282.01
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
99283 - Level 3 - Lynx Visit Level
|
Facility
IP
|
$1,137.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
3031288
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$557.13 |
| Max. Negotiated Rate |
$1,046.04 |
| Rate for Payer: Aetna Commercial |
$1,023.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$602.61
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,046.04
|
| Rate for Payer: Health EOS Commercial |
$1,011.93
|
| Rate for Payer: HFN Commercial |
$1,046.04
|
| Rate for Payer: Multiplan Commercial |
$909.60
|
| Rate for Payer: NAPHCARE Commercial |
$682.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.04
|
| Rate for Payer: Quartz Beloit One Network |
$557.13
|
| Rate for Payer: Quartz Commercial |
$682.20
|
| Rate for Payer: WEA Trust Commercial |
$625.35
|
| Rate for Payer: WPS Commercial |
$842.18
|
|
|
99284 - Level 4 - Lynx Visit Level
|
Facility
OP
|
$1,768.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
3031287
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$437.77 |
| Max. Negotiated Rate |
$4,372.00 |
| Rate for Payer: Aetna Commercial |
$1,591.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,520.48
|
| Rate for Payer: Aetna Managed Medicare |
$437.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,302.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,138.00
|
| Rate for Payer: Anthem Medicare Advantage |
$437.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$937.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$437.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$437.77
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,626.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$437.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$989.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$437.77
|
| Rate for Payer: Health EOS Commercial |
$1,573.52
|
| Rate for Payer: HFN Commercial |
$1,626.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,628.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$437.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$437.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$437.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$437.77
|
| Rate for Payer: Multiplan Commercial |
$1,414.40
|
| Rate for Payer: NAPHCARE Commercial |
$656.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,626.56
|
| Rate for Payer: Quartz Beloit One Network |
$866.32
|
| Rate for Payer: Quartz Commercial |
$1,149.20
|
| Rate for Payer: Quartz Medicare Advantage |
$437.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$437.77
|
| Rate for Payer: United Healthcare PPO |
$1,300.00
|
| Rate for Payer: WEA Trust Commercial |
$972.40
|
| Rate for Payer: Wellcare Medicare |
$437.77
|
| Rate for Payer: WPS Commercial |
$1,309.56
|
|
|
99284 - Level 4 - Lynx Visit Level
|
Facility
IP
|
$1,768.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
3031287
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$866.32 |
| Max. Negotiated Rate |
$1,626.56 |
| Rate for Payer: Aetna Commercial |
$1,591.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$937.04
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,626.56
|
| Rate for Payer: Health EOS Commercial |
$1,573.52
|
| Rate for Payer: HFN Commercial |
$1,626.56
|
| Rate for Payer: Multiplan Commercial |
$1,414.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,060.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,626.56
|
| Rate for Payer: Quartz Beloit One Network |
$866.32
|
| Rate for Payer: Quartz Commercial |
$1,060.80
|
| Rate for Payer: WEA Trust Commercial |
$972.40
|
| Rate for Payer: WPS Commercial |
$1,309.56
|
|
|
99285 - Level 5 - Lynx Visit Level
|
Facility
IP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
3031286
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,547.42 |
| Max. Negotiated Rate |
$2,905.36 |
| Rate for Payer: Aetna Commercial |
$2,842.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,673.74
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$2,905.36
|
| Rate for Payer: Health EOS Commercial |
$2,810.62
|
| Rate for Payer: HFN Commercial |
$2,905.36
|
| Rate for Payer: Multiplan Commercial |
$2,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,894.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,905.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,547.42
|
| Rate for Payer: Quartz Commercial |
$1,894.80
|
| Rate for Payer: WEA Trust Commercial |
$1,736.90
|
| Rate for Payer: WPS Commercial |
$2,339.13
|
|
|
99285 - Level 5 - Lynx Visit Level
|
Facility
OP
|
$3,158.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
3031286
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$634.87 |
| Max. Negotiated Rate |
$4,372.00 |
| Rate for Payer: Aetna Commercial |
$2,842.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,715.88
|
| Rate for Payer: Aetna Managed Medicare |
$634.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,302.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,138.00
|
| Rate for Payer: Anthem Medicare Advantage |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,673.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$634.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$634.87
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$2,905.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$634.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,767.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$634.87
|
| Rate for Payer: Health EOS Commercial |
$2,810.62
|
| Rate for Payer: HFN Commercial |
$2,905.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,361.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$634.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$634.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$634.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$634.87
|
| Rate for Payer: Multiplan Commercial |
$2,526.40
|
| Rate for Payer: NAPHCARE Commercial |
$952.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,905.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,547.42
|
| Rate for Payer: Quartz Commercial |
$2,052.70
|
| Rate for Payer: Quartz Medicare Advantage |
$634.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$634.87
|
| Rate for Payer: United Healthcare PPO |
$2,462.00
|
| Rate for Payer: WEA Trust Commercial |
$1,736.90
|
| Rate for Payer: Wellcare Medicare |
$634.87
|
| Rate for Payer: WPS Commercial |
$2,339.13
|
|
|
99291 - Critical Care - Lynx Visit Level
|
Facility
OP
|
$4,460.00
|
|
|
Service Code
|
CPT 99291
|
| Hospital Charge Code |
3031311
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$877.08 |
| Max. Negotiated Rate |
$5,245.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$877.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,245.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,020.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,819.00
|
| Rate for Payer: Anthem Medicare Advantage |
$877.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$877.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$877.08
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$877.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$877.08
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,262.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$877.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$877.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$877.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$877.08
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,315.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$877.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$877.08
|
| Rate for Payer: United Healthcare PPO |
$3,078.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: Wellcare Medicare |
$877.08
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
99291 - Critical Care - Lynx Visit Level
|
Facility
IP
|
$4,460.00
|
|
|
Service Code
|
CPT 99291
|
| Hospital Charge Code |
3031311
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651 VFC
|
Facility
IP
|
$20.83
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5883634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651 VFC
|
Professional
|
$20.83
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5883634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$398.07 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$398.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$398.07
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$283.77
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651 VFC
|
Facility
OP
|
$20.83
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5883634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
AAA AORTO-UNI-ILIAC GRAFT W/ RUPTURE
|
Facility
OP
|
$20,072.00
|
|
|
Service Code
|
CPT 34704
|
| Hospital Charge Code |
6179650
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$5,620.16 |
| Max. Negotiated Rate |
$80,288.00 |
| Rate for Payer: Aetna Commercial |
$18,064.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,261.92
|
| Rate for Payer: Aetna Managed Medicare |
$5,620.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,638.16
|
| Rate for Payer: Cash Price |
$6,021.60
|
| Rate for Payer: Cash Price |
$6,021.60
|
| Rate for Payer: Cash Price |
$6,021.60
|
| Rate for Payer: Cigna Commercial |
$18,466.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$17,864.08
|
| Rate for Payer: HFN Commercial |
$18,466.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,054.00
|
| Rate for Payer: Multiplan Commercial |
$16,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,043.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,466.24
|
| Rate for Payer: Quartz Beloit One Network |
$9,835.28
|
| Rate for Payer: Quartz Commercial |
$13,046.80
|
| Rate for Payer: Quartz Medicare Advantage |
$12,043.20
|
| Rate for Payer: The Alliance Commercial |
$80,288.00
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: WEA Trust Commercial |
$11,039.60
|
| Rate for Payer: WPS Commercial |
$14,867.33
|
|
|
AAA AORTO-UNI-ILIAC GRAFT W/ RUPTURE
|
Facility
IP
|
$20,072.00
|
|
|
Service Code
|
CPT 34704
|
| Hospital Charge Code |
6179650
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$9,835.28 |
| Max. Negotiated Rate |
$18,466.24 |
| Rate for Payer: Aetna Commercial |
$18,064.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,638.16
|
| Rate for Payer: Cash Price |
$6,021.60
|
| Rate for Payer: Cigna Commercial |
$18,466.24
|
| Rate for Payer: Health EOS Commercial |
$17,864.08
|
| Rate for Payer: HFN Commercial |
$18,466.24
|
| Rate for Payer: Multiplan Commercial |
$16,057.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,043.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18,466.24
|
| Rate for Payer: Quartz Beloit One Network |
$9,835.28
|
| Rate for Payer: Quartz Commercial |
$12,043.20
|
| Rate for Payer: WEA Trust Commercial |
$11,039.60
|
| Rate for Payer: WPS Commercial |
$14,867.33
|
|
|
AAA EXTENSION-DELAYED EA ADD VESSEL
|
Facility
OP
|
$37,569.00
|
|
|
Service Code
|
CPT 34711
|
| Hospital Charge Code |
5416675
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$10,519.32 |
| Max. Negotiated Rate |
$150,276.00 |
| Rate for Payer: Aetna Commercial |
$33,812.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$10,519.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,419.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,784.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,033.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,911.57
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$34,563.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$33,436.41
|
| Rate for Payer: HFN Commercial |
$34,563.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,176.75
|
| Rate for Payer: Multiplan Commercial |
$30,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$22,541.40
|
| Rate for Payer: Preferred Network Access Commercial |
$34,563.48
|
| Rate for Payer: Quartz Beloit One Network |
$18,408.81
|
| Rate for Payer: Quartz Commercial |
$24,419.85
|
| Rate for Payer: Quartz Medicare Advantage |
$22,541.40
|
| Rate for Payer: The Alliance Commercial |
$150,276.00
|
| Rate for Payer: United Healthcare PPO |
$28,176.75
|
| Rate for Payer: WEA Trust Commercial |
$20,662.95
|
| Rate for Payer: WPS Commercial |
$27,827.36
|
|
|
AAA EXTENSION-DELAYED EA ADD VESSEL
|
Facility
IP
|
$37,569.00
|
|
|
Service Code
|
CPT 34711
|
| Hospital Charge Code |
5416675
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$18,408.81 |
| Max. Negotiated Rate |
$34,563.48 |
| Rate for Payer: Aetna Commercial |
$33,812.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,911.57
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$34,563.48
|
| Rate for Payer: Health EOS Commercial |
$33,436.41
|
| Rate for Payer: HFN Commercial |
$34,563.48
|
| Rate for Payer: Multiplan Commercial |
$30,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$22,541.40
|
| Rate for Payer: Preferred Network Access Commercial |
$34,563.48
|
| Rate for Payer: Quartz Beloit One Network |
$18,408.81
|
| Rate for Payer: Quartz Commercial |
$22,541.40
|
| Rate for Payer: WEA Trust Commercial |
$20,662.95
|
| Rate for Payer: WPS Commercial |
$27,827.36
|
|
|
AAA EXTENSION PROSTHESES-DELAYED
|
Facility
OP
|
$37,569.00
|
|
|
Service Code
|
CPT 34710
|
| Hospital Charge Code |
5416680
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$10,519.32 |
| Max. Negotiated Rate |
$150,276.00 |
| Rate for Payer: Aetna Commercial |
$33,812.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$10,519.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,419.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,784.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,033.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,911.57
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$34,563.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$33,436.41
|
| Rate for Payer: HFN Commercial |
$34,563.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,176.75
|
| Rate for Payer: Multiplan Commercial |
$30,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$22,541.40
|
| Rate for Payer: Preferred Network Access Commercial |
$34,563.48
|
| Rate for Payer: Quartz Beloit One Network |
$18,408.81
|
| Rate for Payer: Quartz Commercial |
$24,419.85
|
| Rate for Payer: Quartz Medicare Advantage |
$22,541.40
|
| Rate for Payer: The Alliance Commercial |
$150,276.00
|
| Rate for Payer: United Healthcare PPO |
$28,176.75
|
| Rate for Payer: WEA Trust Commercial |
$20,662.95
|
| Rate for Payer: WPS Commercial |
$27,827.36
|
|
|
AAA EXTENSION PROSTHESES-DELAYED
|
Facility
IP
|
$37,569.00
|
|
|
Service Code
|
CPT 34710
|
| Hospital Charge Code |
5416680
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$18,408.81 |
| Max. Negotiated Rate |
$34,563.48 |
| Rate for Payer: Aetna Commercial |
$33,812.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19,911.57
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$34,563.48
|
| Rate for Payer: Health EOS Commercial |
$33,436.41
|
| Rate for Payer: HFN Commercial |
$34,563.48
|
| Rate for Payer: Multiplan Commercial |
$30,055.20
|
| Rate for Payer: NAPHCARE Commercial |
$22,541.40
|
| Rate for Payer: Preferred Network Access Commercial |
$34,563.48
|
| Rate for Payer: Quartz Beloit One Network |
$18,408.81
|
| Rate for Payer: Quartz Commercial |
$22,541.40
|
| Rate for Payer: WEA Trust Commercial |
$20,662.95
|
| Rate for Payer: WPS Commercial |
$27,827.36
|
|
|
AAA EXTENSION PROSTHESIS
|
Facility
IP
|
$39,014.00
|
|
|
Service Code
|
CPT 34709
|
| Hospital Charge Code |
5416679
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$19,116.86 |
| Max. Negotiated Rate |
$35,892.88 |
| Rate for Payer: Aetna Commercial |
$35,112.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,677.42
|
| Rate for Payer: Cash Price |
$11,704.20
|
| Rate for Payer: Cigna Commercial |
$35,892.88
|
| Rate for Payer: Health EOS Commercial |
$34,722.46
|
| Rate for Payer: HFN Commercial |
$35,892.88
|
| Rate for Payer: Multiplan Commercial |
$31,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$23,408.40
|
| Rate for Payer: Preferred Network Access Commercial |
$35,892.88
|
| Rate for Payer: Quartz Beloit One Network |
$19,116.86
|
| Rate for Payer: Quartz Commercial |
$23,408.40
|
| Rate for Payer: WEA Trust Commercial |
$21,457.70
|
| Rate for Payer: WPS Commercial |
$28,897.67
|
|
|
AAA EXTENSION PROSTHESIS
|
Facility
OP
|
$39,014.00
|
|
|
Service Code
|
CPT 34709
|
| Hospital Charge Code |
5416679
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$10,923.92 |
| Max. Negotiated Rate |
$156,056.00 |
| Rate for Payer: Aetna Commercial |
$35,112.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,552.04
|
| Rate for Payer: Aetna Managed Medicare |
$10,923.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,359.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,507.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,677.42
|
| Rate for Payer: Cash Price |
$11,704.20
|
| Rate for Payer: Cash Price |
$11,704.20
|
| Rate for Payer: Cigna Commercial |
$35,892.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$34,722.46
|
| Rate for Payer: HFN Commercial |
$35,892.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,260.50
|
| Rate for Payer: Multiplan Commercial |
$31,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$23,408.40
|
| Rate for Payer: Preferred Network Access Commercial |
$35,892.88
|
| Rate for Payer: Quartz Beloit One Network |
$19,116.86
|
| Rate for Payer: Quartz Commercial |
$25,359.10
|
| Rate for Payer: Quartz Medicare Advantage |
$23,408.40
|
| Rate for Payer: The Alliance Commercial |
$156,056.00
|
| Rate for Payer: United Healthcare PPO |
$29,260.50
|
| Rate for Payer: WEA Trust Commercial |
$21,457.70
|
| Rate for Payer: WPS Commercial |
$28,897.67
|
|
|
AAA FIXATON DEVICE(S) TO ENDOGRAFT
|
Facility
OP
|
$16,846.00
|
|
|
Service Code
|
CPT 34712
|
| Hospital Charge Code |
5581970
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,103.00 |
| Max. Negotiated Rate |
$67,384.00 |
| Rate for Payer: Aetna Commercial |
$15,161.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,487.56
|
| Rate for Payer: Aetna Managed Medicare |
$4,716.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,928.38
|
| Rate for Payer: Cash Price |
$5,053.80
|
| Rate for Payer: Cash Price |
$5,053.80
|
| Rate for Payer: Cash Price |
$5,053.80
|
| Rate for Payer: Cigna Commercial |
$15,498.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$14,992.94
|
| Rate for Payer: HFN Commercial |
$15,498.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,634.50
|
| Rate for Payer: Multiplan Commercial |
$13,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,498.32
|
| Rate for Payer: Quartz Beloit One Network |
$8,254.54
|
| Rate for Payer: Quartz Commercial |
$10,949.90
|
| Rate for Payer: Quartz Medicare Advantage |
$10,107.60
|
| Rate for Payer: The Alliance Commercial |
$67,384.00
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: WEA Trust Commercial |
$9,265.30
|
| Rate for Payer: WPS Commercial |
$12,477.83
|
|
|
AAA FIXATON DEVICE(S) TO ENDOGRAFT
|
Facility
IP
|
$16,846.00
|
|
|
Service Code
|
CPT 34712
|
| Hospital Charge Code |
5581970
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$8,254.54 |
| Max. Negotiated Rate |
$15,498.32 |
| Rate for Payer: Aetna Commercial |
$15,161.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,928.38
|
| Rate for Payer: Cash Price |
$5,053.80
|
| Rate for Payer: Cigna Commercial |
$15,498.32
|
| Rate for Payer: Health EOS Commercial |
$14,992.94
|
| Rate for Payer: HFN Commercial |
$15,498.32
|
| Rate for Payer: Multiplan Commercial |
$13,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,498.32
|
| Rate for Payer: Quartz Beloit One Network |
$8,254.54
|
| Rate for Payer: Quartz Commercial |
$10,107.60
|
| Rate for Payer: WEA Trust Commercial |
$9,265.30
|
| Rate for Payer: WPS Commercial |
$12,477.83
|
|
|
AAA GRAFT-MAIN BODY & BIL ILIAC
|
Facility
OP
|
$45,749.00
|
|
|
Service Code
|
CPT 34705
|
| Hospital Charge Code |
5416674
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$11,874.87 |
| Max. Negotiated Rate |
$182,996.00 |
| Rate for Payer: Aetna Commercial |
$41,174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39,344.14
|
| Rate for Payer: Aetna Managed Medicare |
$12,809.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,736.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,874.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,959.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24,246.97
|
| Rate for Payer: Cash Price |
$13,724.70
|
| Rate for Payer: Cash Price |
$13,724.70
|
| Rate for Payer: Cigna Commercial |
$42,089.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$40,716.61
|
| Rate for Payer: HFN Commercial |
$42,089.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,311.75
|
| Rate for Payer: Multiplan Commercial |
$36,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$27,449.40
|
| Rate for Payer: Preferred Network Access Commercial |
$42,089.08
|
| Rate for Payer: Quartz Beloit One Network |
$22,417.01
|
| Rate for Payer: Quartz Commercial |
$29,736.85
|
| Rate for Payer: Quartz Medicare Advantage |
$27,449.40
|
| Rate for Payer: The Alliance Commercial |
$182,996.00
|
| Rate for Payer: United Healthcare PPO |
$34,311.75
|
| Rate for Payer: WEA Trust Commercial |
$25,161.95
|
| Rate for Payer: WPS Commercial |
$33,886.28
|
|
