|
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 |
$116.19 |
| Max. Negotiated Rate |
$218.15 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
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 |
$161.58 |
| Max. Negotiated Rate |
$666.64 |
| Rate for Payer: Aetna Commercial |
$590.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$564.37
|
| Rate for Payer: Aetna Managed Medicare |
$161.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$477.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$453.44
|
| Rate for Payer: Anthem Medicare Advantage |
$161.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$347.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$161.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$161.58
|
| 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 |
$603.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$161.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$367.24
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$161.58
|
| Rate for Payer: Health EOS Commercial |
$584.05
|
| Rate for Payer: HFN Commercial |
$603.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$601.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$161.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$161.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$161.58
|
| Rate for Payer: Multiplan Commercial |
$524.99
|
| Rate for Payer: NAPHCARE Commercial |
$242.38
|
| Rate for Payer: Preferred Network Access Commercial |
$603.74
|
| Rate for Payer: Quartz Beloit One Network |
$321.56
|
| Rate for Payer: Quartz Commercial |
$426.56
|
| Rate for Payer: Quartz Medicare Advantage |
$161.58
|
| Rate for Payer: The Alliance Commercial |
$646.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$161.58
|
| Rate for Payer: United Healthcare PPO |
$547.04
|
| Rate for Payer: WEA Trust Commercial |
$360.93
|
| Rate for Payer: Wellcare Medicare |
$161.58
|
| Rate for Payer: WPS Commercial |
$486.06
|
|
|
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 |
$321.56 |
| Max. Negotiated Rate |
$603.74 |
| Rate for Payer: Aetna Commercial |
$590.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$564.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$347.81
|
| Rate for Payer: Cash Price |
$189.30
|
| Rate for Payer: Cigna Commercial |
$603.74
|
| Rate for Payer: Health EOS Commercial |
$584.05
|
| Rate for Payer: HFN Commercial |
$603.74
|
| Rate for Payer: Multiplan Commercial |
$524.99
|
| Rate for Payer: Preferred Network Access Commercial |
$603.74
|
| Rate for Payer: Quartz Beloit One Network |
$321.56
|
| Rate for Payer: Quartz Commercial |
$393.74
|
| Rate for Payer: WEA Trust Commercial |
$360.93
|
| Rate for Payer: WPS Commercial |
$486.06
|
|
|
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 |
$579.42 |
| Max. Negotiated Rate |
$1,087.88 |
| Rate for Payer: Aetna Commercial |
$1,064.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.71
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cigna Commercial |
$1,087.88
|
| Rate for Payer: Health EOS Commercial |
$1,052.41
|
| Rate for Payer: HFN Commercial |
$1,087.88
|
| Rate for Payer: Multiplan Commercial |
$945.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.88
|
| Rate for Payer: Quartz Beloit One Network |
$579.42
|
| Rate for Payer: Quartz Commercial |
$709.49
|
| Rate for Payer: WEA Trust Commercial |
$650.36
|
| Rate for Payer: WPS Commercial |
$875.83
|
|
|
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 |
$287.28 |
| Max. Negotiated Rate |
$1,516.32 |
| Rate for Payer: Aetna Commercial |
$1,064.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.93
|
| Rate for Payer: Aetna Managed Medicare |
$287.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,516.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$955.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$907.92
|
| Rate for Payer: Anthem Medicare Advantage |
$287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$287.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$287.28
|
| 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 |
$1,087.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$287.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$287.28
|
| Rate for Payer: Health EOS Commercial |
$1,052.41
|
| Rate for Payer: HFN Commercial |
$1,087.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,068.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$287.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$287.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$287.28
|
| Rate for Payer: Multiplan Commercial |
$945.98
|
| Rate for Payer: NAPHCARE Commercial |
$430.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.88
|
| Rate for Payer: Quartz Beloit One Network |
$579.42
|
| Rate for Payer: Quartz Commercial |
$768.61
|
| Rate for Payer: Quartz Medicare Advantage |
$287.28
|
| Rate for Payer: The Alliance Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$287.28
|
| Rate for Payer: United Healthcare PPO |
$1,265.68
|
| Rate for Payer: WEA Trust Commercial |
$650.36
|
| Rate for Payer: Wellcare Medicare |
$287.28
|
| Rate for Payer: WPS Commercial |
$875.83
|
|
|
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 |
$439.12 |
| Max. Negotiated Rate |
$4,546.88 |
| Rate for Payer: Aetna Commercial |
$1,654.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.30
|
| Rate for Payer: Aetna Managed Medicare |
$439.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,546.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,263.52
|
| Rate for Payer: Anthem Medicare Advantage |
$439.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$439.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$439.12
|
| 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 |
$1,691.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$439.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,028.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$439.12
|
| Rate for Payer: Health EOS Commercial |
$1,636.46
|
| Rate for Payer: HFN Commercial |
$1,691.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,633.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$439.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$439.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$439.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$439.12
|
| Rate for Payer: Multiplan Commercial |
$1,470.98
|
| Rate for Payer: NAPHCARE Commercial |
$658.68
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.62
|
| Rate for Payer: Quartz Beloit One Network |
$900.97
|
| Rate for Payer: Quartz Commercial |
$1,195.17
|
| Rate for Payer: Quartz Medicare Advantage |
$439.12
|
| Rate for Payer: The Alliance Commercial |
$1,756.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$439.12
|
| Rate for Payer: United Healthcare PPO |
$1,352.00
|
| Rate for Payer: WEA Trust Commercial |
$1,011.30
|
| Rate for Payer: Wellcare Medicare |
$439.12
|
| Rate for Payer: WPS Commercial |
$1,361.89
|
|
|
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 |
$900.97 |
| Max. Negotiated Rate |
$1,691.62 |
| Rate for Payer: Aetna Commercial |
$1,654.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,581.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.52
|
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Cigna Commercial |
$1,691.62
|
| Rate for Payer: Health EOS Commercial |
$1,636.46
|
| Rate for Payer: HFN Commercial |
$1,691.62
|
| Rate for Payer: Multiplan Commercial |
$1,470.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,691.62
|
| Rate for Payer: Quartz Beloit One Network |
$900.97
|
| Rate for Payer: Quartz Commercial |
$1,103.23
|
| Rate for Payer: WEA Trust Commercial |
$1,011.30
|
| Rate for Payer: WPS Commercial |
$1,361.89
|
|
|
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 |
$626.74 |
| Max. Negotiated Rate |
$4,546.88 |
| Rate for Payer: Aetna Commercial |
$2,955.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,824.52
|
| Rate for Payer: Aetna Managed Medicare |
$626.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,546.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,434.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,263.52
|
| Rate for Payer: Anthem Medicare Advantage |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,740.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$626.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$626.74
|
| 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 |
$3,021.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$626.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,837.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$626.74
|
| Rate for Payer: Health EOS Commercial |
$2,923.04
|
| Rate for Payer: HFN Commercial |
$3,021.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$626.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$626.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$626.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$626.74
|
| Rate for Payer: Multiplan Commercial |
$2,627.46
|
| Rate for Payer: NAPHCARE Commercial |
$940.10
|
| Rate for Payer: Preferred Network Access Commercial |
$3,021.57
|
| Rate for Payer: Quartz Beloit One Network |
$1,609.32
|
| Rate for Payer: Quartz Commercial |
$2,134.81
|
| Rate for Payer: Quartz Medicare Advantage |
$626.74
|
| Rate for Payer: The Alliance Commercial |
$2,506.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$626.74
|
| Rate for Payer: United Healthcare PPO |
$2,560.48
|
| Rate for Payer: WEA Trust Commercial |
$1,806.38
|
| Rate for Payer: Wellcare Medicare |
$626.74
|
| Rate for Payer: WPS Commercial |
$2,432.61
|
|
|
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 |
$1,609.32 |
| Max. Negotiated Rate |
$3,021.57 |
| Rate for Payer: Aetna Commercial |
$2,955.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,824.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,740.69
|
| Rate for Payer: Cash Price |
$947.40
|
| Rate for Payer: Cigna Commercial |
$3,021.57
|
| Rate for Payer: Health EOS Commercial |
$2,923.04
|
| Rate for Payer: HFN Commercial |
$3,021.57
|
| Rate for Payer: Multiplan Commercial |
$2,627.46
|
| Rate for Payer: Preferred Network Access Commercial |
$3,021.57
|
| Rate for Payer: Quartz Beloit One Network |
$1,609.32
|
| Rate for Payer: Quartz Commercial |
$1,970.59
|
| Rate for Payer: WEA Trust Commercial |
$1,806.38
|
| Rate for Payer: WPS Commercial |
$2,432.61
|
|
|
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 |
$869.30 |
| Max. Negotiated Rate |
$5,454.80 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$869.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,454.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,180.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,971.76
|
| Rate for Payer: Anthem Medicare Advantage |
$869.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$869.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$869.30
|
| 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 |
$4,267.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$869.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$869.30
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,233.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$869.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$869.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$869.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$869.30
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$1,303.96
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$869.30
|
| Rate for Payer: The Alliance Commercial |
$3,477.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$869.30
|
| Rate for Payer: United Healthcare PPO |
$3,201.12
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: Wellcare Medicare |
$869.30
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
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 |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5879706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$259.92 |
| Max. Negotiated Rate |
$561.18 |
| Rate for Payer: Aetna Commercial |
$561.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$561.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$342.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.43
|
| Rate for Payer: Health EOS Commercial |
$537.56
|
| Rate for Payer: HFN Commercial |
$561.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$413.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$413.99
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: Preferred Network Access Commercial |
$561.18
|
| Rate for Payer: Quartz Beloit One Network |
$259.92
|
| Rate for Payer: Quartz Commercial |
$336.71
|
| Rate for Payer: The Alliance Commercial |
$295.36
|
| Rate for Payer: United Healthcare Medicaid |
$342.25
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5879706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.40 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$165.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$383.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$283.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.58
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$443.04
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$354.43
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$383.97
|
| Rate for Payer: Quartz Medicare Advantage |
$354.43
|
| Rate for Payer: The Alliance Commercial |
$295.36
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5879706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$289.45 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$354.43
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
9VHPV VACC 2/3 DOSE SCHED IM USE - 90651 VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
5883634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$413.99 |
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$20.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$342.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.00
|
| Rate for Payer: Health EOS Commercial |
$19.71
|
| Rate for Payer: HFN Commercial |
$20.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$413.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$413.99
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$20.58
|
| Rate for Payer: Quartz Beloit One Network |
$9.53
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicaid |
$342.25
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$10.61 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
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 |
$6.07 |
| Max. Negotiated Rate |
$19.93 |
| Rate for Payer: Aetna Commercial |
$19.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.63
|
| Rate for Payer: Aetna Managed Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.48
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$19.28
|
| Rate for Payer: HFN Commercial |
$19.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.25
|
| Rate for Payer: Multiplan Commercial |
$17.33
|
| Rate for Payer: NAPHCARE Commercial |
$13.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.93
|
| Rate for Payer: Quartz Beloit One Network |
$10.61
|
| Rate for Payer: Quartz Commercial |
$14.08
|
| Rate for Payer: Quartz Medicare Advantage |
$13.00
|
| Rate for Payer: The Alliance Commercial |
$10.83
|
| Rate for Payer: WEA Trust Commercial |
$11.91
|
| Rate for Payer: WPS Commercial |
$16.05
|
|
|
AAA 16Fr Introducer
|
Facility
|
IP
|
$3,828.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550888
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,950.75 |
| Max. Negotiated Rate |
$3,662.63 |
| Rate for Payer: Aetna Commercial |
$3,583.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,423.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,109.99
|
| Rate for Payer: Cash Price |
$1,148.40
|
| Rate for Payer: Cigna Commercial |
$3,662.63
|
| Rate for Payer: Health EOS Commercial |
$3,543.20
|
| Rate for Payer: HFN Commercial |
$3,662.63
|
| Rate for Payer: Multiplan Commercial |
$3,184.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,662.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,950.75
|
| Rate for Payer: Quartz Commercial |
$2,388.67
|
| Rate for Payer: WEA Trust Commercial |
$2,189.62
|
| Rate for Payer: WPS Commercial |
$2,948.71
|
|
|
AAA 16Fr Introducer
|
Facility
|
OP
|
$3,828.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550888
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,114.71 |
| Max. Negotiated Rate |
$3,662.63 |
| Rate for Payer: Aetna Commercial |
$3,583.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,423.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,114.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,587.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,990.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,910.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,109.99
|
| Rate for Payer: Cash Price |
$1,148.40
|
| Rate for Payer: Cigna Commercial |
$3,662.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,227.90
|
| Rate for Payer: Health EOS Commercial |
$3,543.20
|
| Rate for Payer: HFN Commercial |
$3,662.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,985.84
|
| Rate for Payer: Multiplan Commercial |
$3,184.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,388.67
|
| Rate for Payer: Preferred Network Access Commercial |
$3,662.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,950.75
|
| Rate for Payer: Quartz Commercial |
$2,587.73
|
| Rate for Payer: Quartz Medicare Advantage |
$2,388.67
|
| Rate for Payer: The Alliance Commercial |
$1,990.56
|
| Rate for Payer: WEA Trust Commercial |
$2,189.62
|
| Rate for Payer: WPS Commercial |
$2,948.71
|
|
|
AAA 16Fr Introducer
|
Professional
|
Both
|
$3,828.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550888
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,751.69 |
| Max. Negotiated Rate |
$3,782.06 |
| Rate for Payer: Aetna Commercial |
$3,782.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,423.76
|
| Rate for Payer: Cash Price |
$1,148.40
|
| Rate for Payer: Cigna Commercial |
$3,782.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,990.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,388.67
|
| Rate for Payer: Health EOS Commercial |
$3,622.82
|
| Rate for Payer: HFN Commercial |
$3,782.06
|
| Rate for Payer: Multiplan Commercial |
$3,184.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,782.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,751.69
|
| Rate for Payer: Quartz Commercial |
$2,269.24
|
| Rate for Payer: The Alliance Commercial |
$1,990.56
|
| Rate for Payer: WEA Trust Commercial |
$2,189.62
|
| Rate for Payer: WPS Commercial |
$2,948.71
|
|
|
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 |
$10,228.69 |
| Max. Negotiated Rate |
$19,204.89 |
| Rate for Payer: Aetna Commercial |
$18,787.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,952.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,063.69
|
| Rate for Payer: Cash Price |
$6,021.60
|
| Rate for Payer: Cigna Commercial |
$19,204.89
|
| Rate for Payer: Health EOS Commercial |
$18,578.64
|
| Rate for Payer: HFN Commercial |
$19,204.89
|
| Rate for Payer: Multiplan Commercial |
$16,699.90
|
| Rate for Payer: Preferred Network Access Commercial |
$19,204.89
|
| Rate for Payer: Quartz Beloit One Network |
$10,228.69
|
| Rate for Payer: Quartz Commercial |
$12,524.93
|
| Rate for Payer: WEA Trust Commercial |
$11,481.18
|
| Rate for Payer: WPS Commercial |
$15,461.46
|
|
|
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 |
$5,844.97 |
| Max. Negotiated Rate |
$19,394.96 |
| Rate for Payer: Aetna Commercial |
$18,787.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,952.40
|
| Rate for Payer: Aetna Managed Medicare |
$5,844.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,394.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,394.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,919.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,063.69
|
| 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 |
$19,204.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$18,578.64
|
| Rate for Payer: HFN Commercial |
$19,204.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,656.16
|
| Rate for Payer: Multiplan Commercial |
$16,699.90
|
| Rate for Payer: NAPHCARE Commercial |
$12,524.93
|
| Rate for Payer: Preferred Network Access Commercial |
$19,204.89
|
| Rate for Payer: Quartz Beloit One Network |
$10,228.69
|
| Rate for Payer: Quartz Commercial |
$13,568.67
|
| Rate for Payer: Quartz Medicare Advantage |
$12,524.93
|
| Rate for Payer: The Alliance Commercial |
$7,287.99
|
| Rate for Payer: United Healthcare PPO |
$9,979.84
|
| Rate for Payer: WEA Trust Commercial |
$11,481.18
|
| Rate for Payer: WPS Commercial |
$15,461.46
|
|
|
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 |
$955.18 |
| Max. Negotiated Rate |
$35,946.02 |
| Rate for Payer: Aetna Commercial |
$35,164.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,601.71
|
| Rate for Payer: Aetna Managed Medicare |
$10,940.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,396.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,535.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,754.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,708.03
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$35,946.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$34,773.87
|
| Rate for Payer: HFN Commercial |
$35,946.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,303.82
|
| Rate for Payer: Multiplan Commercial |
$31,257.41
|
| Rate for Payer: NAPHCARE Commercial |
$23,443.06
|
| Rate for Payer: Preferred Network Access Commercial |
$35,946.02
|
| Rate for Payer: Quartz Beloit One Network |
$19,145.16
|
| Rate for Payer: Quartz Commercial |
$25,396.64
|
| Rate for Payer: Quartz Medicare Advantage |
$23,443.06
|
| Rate for Payer: The Alliance Commercial |
$955.18
|
| Rate for Payer: United Healthcare PPO |
$29,303.82
|
| Rate for Payer: WEA Trust Commercial |
$21,489.47
|
| Rate for Payer: WPS Commercial |
$28,939.40
|
|
|
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 |
$19,145.16 |
| Max. Negotiated Rate |
$35,946.02 |
| Rate for Payer: Aetna Commercial |
$35,164.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,601.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,708.03
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$35,946.02
|
| Rate for Payer: Health EOS Commercial |
$34,773.87
|
| Rate for Payer: HFN Commercial |
$35,946.02
|
| Rate for Payer: Multiplan Commercial |
$31,257.41
|
| Rate for Payer: Preferred Network Access Commercial |
$35,946.02
|
| Rate for Payer: Quartz Beloit One Network |
$19,145.16
|
| Rate for Payer: Quartz Commercial |
$23,443.06
|
| Rate for Payer: WEA Trust Commercial |
$21,489.47
|
| Rate for Payer: WPS Commercial |
$28,939.40
|
|
|
AAA EXTENSION PROSTHESES-DELAYED
|
Facility
|
OP
|
$37,569.00
|
|
|
Service Code
|
CPT 34710
|
| Hospital Charge Code |
5416680
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$2,634.94 |
| Max. Negotiated Rate |
$35,946.02 |
| Rate for Payer: Aetna Commercial |
$35,164.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,601.71
|
| Rate for Payer: Aetna Managed Medicare |
$10,940.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,396.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,535.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,754.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,708.03
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cash Price |
$11,270.70
|
| Rate for Payer: Cigna Commercial |
$35,946.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$34,773.87
|
| Rate for Payer: HFN Commercial |
$35,946.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,303.82
|
| Rate for Payer: Multiplan Commercial |
$31,257.41
|
| Rate for Payer: NAPHCARE Commercial |
$23,443.06
|
| Rate for Payer: Preferred Network Access Commercial |
$35,946.02
|
| Rate for Payer: Quartz Beloit One Network |
$19,145.16
|
| Rate for Payer: Quartz Commercial |
$25,396.64
|
| Rate for Payer: Quartz Medicare Advantage |
$23,443.06
|
| Rate for Payer: The Alliance Commercial |
$2,634.94
|
| Rate for Payer: United Healthcare PPO |
$29,303.82
|
| Rate for Payer: WEA Trust Commercial |
$21,489.47
|
| Rate for Payer: WPS Commercial |
$28,939.40
|
|
