|
BUTTON OLYMPUS BIPOLAR HF 12/30 DEG WA22760S/WA22557C
|
Facility
|
IP
|
$5,794.00
|
|
| Hospital Charge Code |
4510815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,952.62 |
| Max. Negotiated Rate |
$5,543.70 |
| Rate for Payer: Aetna Commercial |
$5,423.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,182.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,193.65
|
| Rate for Payer: Cash Price |
$1,738.20
|
| Rate for Payer: Cigna Commercial |
$5,543.70
|
| Rate for Payer: Health EOS Commercial |
$5,362.93
|
| Rate for Payer: HFN Commercial |
$5,543.70
|
| Rate for Payer: Multiplan Commercial |
$4,820.61
|
| Rate for Payer: Preferred Network Access Commercial |
$5,543.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,952.62
|
| Rate for Payer: Quartz Commercial |
$3,615.46
|
| Rate for Payer: WEA Trust Commercial |
$3,314.17
|
| Rate for Payer: WPS Commercial |
$4,463.12
|
|
|
BUTTON OLYMPUS BIPOLAR HF 12/30 DEG WA22760S/WA22557C
|
Facility
|
OP
|
$5,794.00
|
|
| Hospital Charge Code |
4510815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,687.21 |
| Max. Negotiated Rate |
$5,543.70 |
| Rate for Payer: Aetna Commercial |
$5,423.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,182.15
|
| Rate for Payer: Aetna Managed Medicare |
$1,687.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,916.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,012.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,892.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,193.65
|
| Rate for Payer: Cash Price |
$1,738.20
|
| Rate for Payer: Cigna Commercial |
$5,543.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,372.11
|
| Rate for Payer: Health EOS Commercial |
$5,362.93
|
| Rate for Payer: HFN Commercial |
$5,543.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,519.32
|
| Rate for Payer: Multiplan Commercial |
$4,820.61
|
| Rate for Payer: NAPHCARE Commercial |
$3,615.46
|
| Rate for Payer: Preferred Network Access Commercial |
$5,543.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,952.62
|
| Rate for Payer: Quartz Commercial |
$3,916.74
|
| Rate for Payer: Quartz Medicare Advantage |
$3,615.46
|
| Rate for Payer: The Alliance Commercial |
$3,012.88
|
| Rate for Payer: WEA Trust Commercial |
$3,314.17
|
| Rate for Payer: WPS Commercial |
$4,463.12
|
|
|
BX BREAST PERCUT W/IMAGE 19102
|
Professional
|
Both
|
$1,076.00
|
|
| Hospital Charge Code |
3013677
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$492.38 |
| Max. Negotiated Rate |
$1,063.09 |
| Rate for Payer: Aetna Commercial |
$1,063.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$962.37
|
| Rate for Payer: Cash Price |
$322.80
|
| Rate for Payer: Cigna Commercial |
$1,063.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$559.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$671.42
|
| Rate for Payer: Health EOS Commercial |
$1,018.33
|
| Rate for Payer: HFN Commercial |
$1,063.09
|
| Rate for Payer: Multiplan Commercial |
$895.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,063.09
|
| Rate for Payer: Quartz Beloit One Network |
$492.38
|
| Rate for Payer: Quartz Commercial |
$637.85
|
| Rate for Payer: The Alliance Commercial |
$559.52
|
| Rate for Payer: WEA Trust Commercial |
$615.47
|
| Rate for Payer: WPS Commercial |
$828.84
|
|
|
BX BREAST PERCUT W/O IMAGE 19100
|
Professional
|
Both
|
$595.00
|
|
|
Service Code
|
CPT 19100
|
| Hospital Charge Code |
3013675
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.60 |
| Max. Negotiated Rate |
$587.86 |
| Rate for Payer: Aetna Commercial |
$587.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.17
|
| Rate for Payer: Aetna Managed Medicare |
$56.60
|
| Rate for Payer: Anthem Medicare Advantage |
$56.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.60
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cigna Commercial |
$587.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.60
|
| Rate for Payer: Health EOS Commercial |
$563.11
|
| Rate for Payer: HFN Commercial |
$587.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$231.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.60
|
| Rate for Payer: Multiplan Commercial |
$495.04
|
| Rate for Payer: NAPHCARE Commercial |
$84.90
|
| Rate for Payer: Preferred Network Access Commercial |
$587.86
|
| Rate for Payer: Quartz Beloit One Network |
$272.27
|
| Rate for Payer: Quartz Commercial |
$352.72
|
| Rate for Payer: Quartz Medicare Advantage |
$56.60
|
| Rate for Payer: The Alliance Commercial |
$240.54
|
| Rate for Payer: United Healthcare Medicaid |
$59.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.60
|
| Rate for Payer: WEA Trust Commercial |
$340.34
|
| Rate for Payer: WPS Commercial |
$254.69
|
|
|
BX Breast w/Device addl Lesion Ultrasound 19084
|
Professional
|
Both
|
$2,494.00
|
|
|
Service Code
|
CPT 19084
|
| Hospital Charge Code |
4586627
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.21 |
| Max. Negotiated Rate |
$2,464.07 |
| Rate for Payer: Aetna Commercial |
$2,464.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,230.63
|
| Rate for Payer: Aetna Managed Medicare |
$63.48
|
| Rate for Payer: Anthem Medicare Advantage |
$63.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.48
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cigna Commercial |
$2,464.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$2,360.32
|
| Rate for Payer: HFN Commercial |
$2,464.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$2,075.01
|
| Rate for Payer: NAPHCARE Commercial |
$95.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,464.07
|
| Rate for Payer: Quartz Beloit One Network |
$1,141.25
|
| Rate for Payer: Quartz Commercial |
$1,478.44
|
| Rate for Payer: Quartz Medicare Advantage |
$63.48
|
| Rate for Payer: The Alliance Commercial |
$269.80
|
| Rate for Payer: United Healthcare Medicaid |
$62.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.48
|
| Rate for Payer: WEA Trust Commercial |
$1,426.57
|
| Rate for Payer: WPS Commercial |
$285.67
|
|
|
BX Done W/Colposcopy Add-On 58110
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 58110
|
| Hospital Charge Code |
3867360
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.21 |
| Max. Negotiated Rate |
$149.43 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$33.21
|
| Rate for Payer: Anthem Medicare Advantage |
$33.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.21
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.21
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$139.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.21
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$49.81
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$33.21
|
| Rate for Payer: The Alliance Commercial |
$141.13
|
| Rate for Payer: United Healthcare Medicaid |
$46.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.21
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$149.43
|
|
|
C02/membane diffuse capacity 9472926
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
CPT 94729 26
|
| Hospital Charge Code |
3015459
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.53 |
| Max. Negotiated Rate |
$111.64 |
| Rate for Payer: Aetna Commercial |
$111.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.07
|
| Rate for Payer: Aetna Managed Medicare |
$9.37
|
| Rate for Payer: Anthem Medicare Advantage |
$9.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.37
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cash Price |
$33.90
|
| Rate for Payer: Cigna Commercial |
$111.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.37
|
| Rate for Payer: Health EOS Commercial |
$106.94
|
| Rate for Payer: HFN Commercial |
$111.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$94.02
|
| Rate for Payer: NAPHCARE Commercial |
$14.06
|
| Rate for Payer: Preferred Network Access Commercial |
$111.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.71
|
| Rate for Payer: Quartz Commercial |
$66.99
|
| Rate for Payer: Quartz Medicare Advantage |
$9.37
|
| Rate for Payer: The Alliance Commercial |
$23.43
|
| Rate for Payer: United Healthcare Medicaid |
$6.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.37
|
| Rate for Payer: WEA Trust Commercial |
$64.64
|
| Rate for Payer: WPS Commercial |
$37.48
|
|
|
C1 Esterase Inhibitor Protein
|
Facility
|
OP
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$292.78 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.69
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$292.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$283.23
|
| Rate for Payer: HFN Commercial |
$292.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$254.59
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$292.78
|
| Rate for Payer: Quartz Beloit One Network |
$155.94
|
| Rate for Payer: Quartz Commercial |
$206.86
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$238.68
|
| Rate for Payer: WEA Trust Commercial |
$175.03
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$235.71
|
|
|
C1 Esterase Inhibitor Protein
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$302.33 |
| Rate for Payer: Aetna Commercial |
$302.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.69
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$302.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$289.60
|
| Rate for Payer: HFN Commercial |
$302.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$254.59
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$302.33
|
| Rate for Payer: Quartz Beloit One Network |
$140.03
|
| Rate for Payer: Quartz Commercial |
$181.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$175.03
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C1 Esterase Inhibitor Protein
|
Facility
|
IP
|
$306.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
1038810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$155.94 |
| Max. Negotiated Rate |
$292.78 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.67
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$292.78
|
| Rate for Payer: Health EOS Commercial |
$283.23
|
| Rate for Payer: HFN Commercial |
$292.78
|
| Rate for Payer: Multiplan Commercial |
$254.59
|
| Rate for Payer: Preferred Network Access Commercial |
$292.78
|
| Rate for Payer: Quartz Beloit One Network |
$155.94
|
| Rate for Payer: Quartz Commercial |
$190.94
|
| Rate for Payer: WEA Trust Commercial |
$175.03
|
| Rate for Payer: WPS Commercial |
$235.71
|
|
|
C1 Inhibitor Functional
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.67 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
C1 Inhibitor Functional
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$69.16 |
| Rate for Payer: Aetna Commercial |
$69.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$69.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$66.25
|
| Rate for Payer: HFN Commercial |
$69.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$69.16
|
| Rate for Payer: Quartz Beloit One Network |
$32.03
|
| Rate for Payer: Quartz Commercial |
$41.50
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C1 Inhibitor Functional
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 86161
|
| Hospital Charge Code |
1038811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$47.32
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
C2 Complement
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$224.85 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$224.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$217.52
|
| Rate for Payer: HFN Commercial |
$224.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$224.85
|
| Rate for Payer: Quartz Beloit One Network |
$119.76
|
| Rate for Payer: Quartz Commercial |
$158.86
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$183.30
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$181.02
|
|
|
C2 Complement
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$224.85 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.53
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$224.85
|
| Rate for Payer: Health EOS Commercial |
$217.52
|
| Rate for Payer: HFN Commercial |
$224.85
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: Preferred Network Access Commercial |
$224.85
|
| Rate for Payer: Quartz Beloit One Network |
$119.76
|
| Rate for Payer: Quartz Commercial |
$146.64
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: WPS Commercial |
$181.02
|
|
|
C2 Complement
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
977887
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$232.18 |
| Rate for Payer: Aetna Commercial |
$232.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.18
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$232.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$222.40
|
| Rate for Payer: HFN Commercial |
$232.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$195.52
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$232.18
|
| Rate for Payer: Quartz Beloit One Network |
$107.54
|
| Rate for Payer: Quartz Commercial |
$139.31
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$134.42
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C3 Complement
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.11 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$137.28
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
C3 Complement
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
C3 Complement
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$217.36 |
| Rate for Payer: Aetna Commercial |
$217.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$217.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$208.21
|
| Rate for Payer: HFN Commercial |
$217.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$217.36
|
| Rate for Payer: Quartz Beloit One Network |
$100.67
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C3 Complement
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$148.72
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
C3 Complement
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$235.14 |
| Rate for Payer: Aetna Commercial |
$235.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$235.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$123.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$225.24
|
| Rate for Payer: HFN Commercial |
$235.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$235.14
|
| Rate for Payer: Quartz Beloit One Network |
$108.91
|
| Rate for Payer: Quartz Commercial |
$141.09
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C3 Complement
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$185.64
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
C4a Level
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$110.66 |
| Rate for Payer: Aetna Commercial |
$110.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$110.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$106.00
|
| Rate for Payer: HFN Commercial |
$110.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$110.66
|
| Rate for Payer: Quartz Beloit One Network |
$51.25
|
| Rate for Payer: Quartz Commercial |
$66.39
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C4a Level
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$75.71
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$87.36
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
|
C4a Level
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
5372654
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$107.16 |
| Rate for Payer: Aetna Commercial |
$104.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.73
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna Commercial |
$107.16
|
| Rate for Payer: Health EOS Commercial |
$103.67
|
| Rate for Payer: HFN Commercial |
$107.16
|
| Rate for Payer: Multiplan Commercial |
$93.18
|
| Rate for Payer: Preferred Network Access Commercial |
$107.16
|
| Rate for Payer: Quartz Beloit One Network |
$57.08
|
| Rate for Payer: Quartz Commercial |
$69.89
|
| Rate for Payer: WEA Trust Commercial |
$64.06
|
| Rate for Payer: WPS Commercial |
$86.27
|
|
