|
CONTAINER BERKELEY SAFETOUCH TISSUE COLLECTION 003984-901
|
Facility
OP
|
$356.00
|
|
| Hospital Charge Code |
2965421
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$99.68 |
| Max. Negotiated Rate |
$1,424.00 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$99.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$231.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$170.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.00
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$213.60
|
| Rate for Payer: The Alliance Commercial |
$1,424.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
CONTAINER BERKELEY SAFETOUCH TISSUE COLLECTION 003984-901
|
Facility
IP
|
$356.00
|
|
| Hospital Charge Code |
2965421
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
CONTAINER SPECIMEN CONVERTOR
|
Facility
OP
|
$59.00
|
|
| Hospital Charge Code |
2963817
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.25
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$35.40
|
| Rate for Payer: The Alliance Commercial |
$236.00
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
CONTAINER SPECIMEN CONVERTOR
|
Facility
IP
|
$59.00
|
|
| Hospital Charge Code |
2963817
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
CONTAINER STERILE SLUSH NACL 2B7231
|
Facility
OP
|
$795.00
|
|
| Hospital Charge Code |
2969354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$715.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$683.70
|
| Rate for Payer: Aetna Managed Medicare |
$222.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$516.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$397.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$421.35
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cigna Commercial |
$731.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$444.88
|
| Rate for Payer: Health EOS Commercial |
$707.55
|
| Rate for Payer: HFN Commercial |
$731.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$596.25
|
| Rate for Payer: Multiplan Commercial |
$636.00
|
| Rate for Payer: NAPHCARE Commercial |
$477.00
|
| Rate for Payer: Preferred Network Access Commercial |
$731.40
|
| Rate for Payer: Quartz Beloit One Network |
$389.55
|
| Rate for Payer: Quartz Commercial |
$516.75
|
| Rate for Payer: Quartz Medicare Advantage |
$477.00
|
| Rate for Payer: The Alliance Commercial |
$3,180.00
|
| Rate for Payer: WEA Trust Commercial |
$437.25
|
| Rate for Payer: WPS Commercial |
$588.86
|
|
|
CONTAINER STERILE SLUSH NACL 2B7231
|
Facility
IP
|
$795.00
|
|
| Hospital Charge Code |
2969354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$389.55 |
| Max. Negotiated Rate |
$731.40 |
| Rate for Payer: Aetna Commercial |
$715.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$421.35
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cigna Commercial |
$731.40
|
| Rate for Payer: Health EOS Commercial |
$707.55
|
| Rate for Payer: HFN Commercial |
$731.40
|
| Rate for Payer: Multiplan Commercial |
$636.00
|
| Rate for Payer: NAPHCARE Commercial |
$477.00
|
| Rate for Payer: Preferred Network Access Commercial |
$731.40
|
| Rate for Payer: Quartz Beloit One Network |
$389.55
|
| Rate for Payer: Quartz Commercial |
$477.00
|
| Rate for Payer: WEA Trust Commercial |
$437.25
|
| Rate for Payer: WPS Commercial |
$588.86
|
|
|
CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPTMENT 95250
|
Facility
IP
|
$276.00
|
|
| Hospital Charge Code |
5959641
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$165.60
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPTMENT 95250
|
Facility
OP
|
$276.00
|
|
| Hospital Charge Code |
5959641
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.36
|
| Rate for Payer: Aetna Managed Medicare |
$77.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.45
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$179.40
|
| Rate for Payer: Quartz Medicare Advantage |
$165.60
|
| Rate for Payer: The Alliance Commercial |
$1,104.00
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT - 95249
|
Professional
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
6075628
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.47 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$262.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.36
|
| Rate for Payer: Aetna Managed Medicare |
$57.73
|
| Rate for Payer: Anthem Medicare Advantage |
$57.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$57.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$57.73
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$138.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.73
|
| Rate for Payer: Health EOS Commercial |
$251.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$191.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$57.73
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$121.44
|
| Rate for Payer: Quartz Commercial |
$157.32
|
| Rate for Payer: Quartz Medicare Advantage |
$57.73
|
| Rate for Payer: The Alliance Commercial |
$144.32
|
| Rate for Payer: United Healthcare Medicaid |
$42.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.73
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: WPS Commercial |
$230.92
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT 95249
|
Facility
IP
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
5949630
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$165.60
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
CONT GLUC MONITORING PATIENT PROVIDED EQUIPMENT 95249
|
Facility
OP
|
$276.00
|
|
|
Service Code
|
CPT 95249
|
| Hospital Charge Code |
5949630
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.36
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.48
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$179.40
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
Continuous Glucose Monitoring Sensor 72 hour minimum; Interpretation
|
Professional
|
$317.00
|
|
|
Service Code
|
CPT 95251
|
| Hospital Charge Code |
1188986
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.35 |
| Max. Negotiated Rate |
$301.15 |
| Rate for Payer: Aetna Commercial |
$301.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$272.62
|
| Rate for Payer: Aetna Managed Medicare |
$33.16
|
| Rate for Payer: Anthem Medicare Advantage |
$33.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.16
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$301.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.16
|
| Rate for Payer: Health EOS Commercial |
$288.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.16
|
| Rate for Payer: Multiplan Commercial |
$253.60
|
| Rate for Payer: Preferred Network Access Commercial |
$301.15
|
| Rate for Payer: Quartz Beloit One Network |
$139.48
|
| Rate for Payer: Quartz Commercial |
$180.69
|
| Rate for Payer: Quartz Medicare Advantage |
$33.16
|
| Rate for Payer: The Alliance Commercial |
$82.90
|
| Rate for Payer: United Healthcare Medicaid |
$23.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.16
|
| Rate for Payer: WEA Trust Commercial |
$174.35
|
| Rate for Payer: WPS Commercial |
$132.64
|
|
|
Continuous Nebulizer Initial setup - Continuous Nebulizer Charge
|
Facility
OP
|
$1,475.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
3576169
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$1,357.00 |
| Rate for Payer: Aetna Commercial |
$1,327.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,268.50
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$958.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$737.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$708.00
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$781.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$1,357.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$825.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$1,312.75
|
| Rate for Payer: HFN Commercial |
$1,357.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$1,180.00
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,357.00
|
| Rate for Payer: Quartz Beloit One Network |
$722.75
|
| Rate for Payer: Quartz Commercial |
$958.75
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$1,106.25
|
| Rate for Payer: WEA Trust Commercial |
$811.25
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$1,092.53
|
|
|
Continuous Nebulizer Initial setup - Continuous Nebulizer Charge
|
Facility
IP
|
$1,475.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
3576169
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$722.75 |
| Max. Negotiated Rate |
$1,357.00 |
| Rate for Payer: Cigna Commercial |
$1,357.00
|
| Rate for Payer: Aetna Commercial |
$1,327.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$781.75
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Health EOS Commercial |
$1,312.75
|
| Rate for Payer: HFN Commercial |
$1,357.00
|
| Rate for Payer: Multiplan Commercial |
$1,180.00
|
| Rate for Payer: NAPHCARE Commercial |
$885.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,357.00
|
| Rate for Payer: Quartz Beloit One Network |
$722.75
|
| Rate for Payer: Quartz Commercial |
$885.00
|
| Rate for Payer: WEA Trust Commercial |
$811.25
|
| Rate for Payer: WPS Commercial |
$1,092.53
|
|
|
Continuous Positive Airway Pressure Initiation And Management 94660
|
Professional
|
$641.00
|
|
|
Service Code
|
CPT 94660
|
| Hospital Charge Code |
1188804
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.08 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Aetna Commercial |
$608.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$551.26
|
| Rate for Payer: Aetna Managed Medicare |
$35.08
|
| Rate for Payer: Anthem Medicare Advantage |
$35.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.08
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$608.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$320.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.08
|
| Rate for Payer: Health EOS Commercial |
$583.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.08
|
| Rate for Payer: Multiplan Commercial |
$512.80
|
| Rate for Payer: Preferred Network Access Commercial |
$608.95
|
| Rate for Payer: Quartz Beloit One Network |
$282.04
|
| Rate for Payer: Quartz Commercial |
$365.37
|
| Rate for Payer: Quartz Medicare Advantage |
$35.08
|
| Rate for Payer: The Alliance Commercial |
$87.70
|
| Rate for Payer: United Healthcare Medicaid |
$71.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.08
|
| Rate for Payer: WEA Trust Commercial |
$352.55
|
| Rate for Payer: WPS Commercial |
$140.32
|
|
|
Continuous Positive Airway Pressure Initiation and Management 9466026
|
Professional
|
$641.00
|
|
|
Service Code
|
CPT 94660 26
|
| Hospital Charge Code |
5230606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$282.04 |
| Max. Negotiated Rate |
$608.95 |
| Rate for Payer: Aetna Commercial |
$608.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$551.26
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$608.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$320.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$384.60
|
| Rate for Payer: Health EOS Commercial |
$583.31
|
| Rate for Payer: Multiplan Commercial |
$512.80
|
| Rate for Payer: Preferred Network Access Commercial |
$608.95
|
| Rate for Payer: Quartz Beloit One Network |
$282.04
|
| Rate for Payer: Quartz Commercial |
$365.37
|
| Rate for Payer: The Alliance Commercial |
$320.50
|
| Rate for Payer: WEA Trust Commercial |
$352.55
|
| Rate for Payer: WPS Commercial |
$474.79
|
|
|
CONTRAST X-RAY EXAM OF AORTA 7560526
|
Professional
|
$752.00
|
|
|
Service Code
|
CPT 75605 26
|
| Hospital Charge Code |
3015289
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.10 |
| Max. Negotiated Rate |
$714.40 |
| Rate for Payer: Aetna Commercial |
$714.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$646.72
|
| Rate for Payer: Aetna Managed Medicare |
$50.10
|
| Rate for Payer: Anthem Medicare Advantage |
$50.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$50.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$50.10
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cigna Commercial |
$714.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.10
|
| Rate for Payer: Health EOS Commercial |
$684.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$182.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$50.10
|
| Rate for Payer: Multiplan Commercial |
$601.60
|
| Rate for Payer: Preferred Network Access Commercial |
$714.40
|
| Rate for Payer: Quartz Beloit One Network |
$330.88
|
| Rate for Payer: Quartz Commercial |
$428.64
|
| Rate for Payer: Quartz Medicare Advantage |
$50.10
|
| Rate for Payer: The Alliance Commercial |
$190.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.10
|
| Rate for Payer: WEA Trust Commercial |
$413.60
|
| Rate for Payer: WPS Commercial |
$250.50
|
|
|
Contrast X-RAY Exam of Aorta 7562526
|
Professional
|
$364.00
|
|
|
Service Code
|
CPT 75625 26
|
| Hospital Charge Code |
3467522
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$226.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$235.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$310.45
|
|
|
Control Nasal Hemorrahage 30901
|
Professional
|
$841.00
|
|
|
Service Code
|
CPT 30901
|
| Hospital Charge Code |
1152805
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.69 |
| Max. Negotiated Rate |
$798.95 |
| Rate for Payer: Aetna Commercial |
$798.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$723.26
|
| Rate for Payer: Aetna Managed Medicare |
$52.17
|
| Rate for Payer: Anthem Medicare Advantage |
$52.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$52.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$52.17
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cash Price |
$252.30
|
| Rate for Payer: Cigna Commercial |
$798.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$420.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.17
|
| Rate for Payer: Health EOS Commercial |
$765.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$184.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$52.17
|
| Rate for Payer: Multiplan Commercial |
$672.80
|
| Rate for Payer: Preferred Network Access Commercial |
$798.95
|
| Rate for Payer: Quartz Beloit One Network |
$370.04
|
| Rate for Payer: Quartz Commercial |
$479.37
|
| Rate for Payer: Quartz Medicare Advantage |
$52.17
|
| Rate for Payer: The Alliance Commercial |
$221.72
|
| Rate for Payer: United Healthcare Medicaid |
$33.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$52.17
|
| Rate for Payer: WEA Trust Commercial |
$462.55
|
| Rate for Payer: WPS Commercial |
$234.76
|
|
|
Control Nasal Hemorrahage; Anterior 3090150
|
Professional
|
$1,474.00
|
|
|
Service Code
|
CPT 30901 50
|
| Hospital Charge Code |
5374713
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.69 |
| Max. Negotiated Rate |
$1,400.30 |
| Rate for Payer: Aetna Commercial |
$1,400.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,267.64
|
| Rate for Payer: Cash Price |
$442.20
|
| Rate for Payer: Cash Price |
$442.20
|
| Rate for Payer: Cigna Commercial |
$1,400.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$737.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.40
|
| Rate for Payer: Health EOS Commercial |
$1,341.34
|
| Rate for Payer: Multiplan Commercial |
$1,179.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.30
|
| Rate for Payer: Quartz Beloit One Network |
$648.56
|
| Rate for Payer: Quartz Commercial |
$840.18
|
| Rate for Payer: The Alliance Commercial |
$737.00
|
| Rate for Payer: United Healthcare Medicaid |
$33.69
|
| Rate for Payer: WEA Trust Commercial |
$810.70
|
| Rate for Payer: WPS Commercial |
$1,091.79
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; INITIAL
|
Facility
OP
|
$12,336.12
|
|
|
Service Code
|
CPT 30905
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$12,336.12 |
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$12,336.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT
|
Facility
OP
|
$12,336.12
|
|
|
Service Code
|
CPT 30906
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$241.43 |
| Max. Negotiated Rate |
$12,336.12 |
| Rate for Payer: Aetna Managed Medicare |
$241.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$241.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$241.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$241.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$241.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$241.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$898.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$241.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$241.43
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$241.43
|
| Rate for Payer: NAPHCARE Commercial |
$362.14
|
| Rate for Payer: Quartz Medicare Advantage |
$241.43
|
| Rate for Payer: The Alliance Commercial |
$12,336.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$241.43
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$241.43
|
|
|
CONTROL OF NOSEBLEED 30903
|
Professional
|
$905.00
|
|
|
Service Code
|
CPT 30903
|
| Hospital Charge Code |
3014364
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.63 |
| Max. Negotiated Rate |
$859.75 |
| Rate for Payer: Aetna Commercial |
$859.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$778.30
|
| Rate for Payer: Aetna Managed Medicare |
$71.37
|
| Rate for Payer: Anthem Medicare Advantage |
$71.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$71.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$71.37
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$859.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.37
|
| Rate for Payer: Health EOS Commercial |
$823.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$253.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$253.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$71.37
|
| Rate for Payer: Multiplan Commercial |
$724.00
|
| Rate for Payer: Preferred Network Access Commercial |
$859.75
|
| Rate for Payer: Quartz Beloit One Network |
$398.20
|
| Rate for Payer: Quartz Commercial |
$515.85
|
| Rate for Payer: Quartz Medicare Advantage |
$71.37
|
| Rate for Payer: The Alliance Commercial |
$303.32
|
| Rate for Payer: United Healthcare Medicaid |
$60.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.37
|
| Rate for Payer: WEA Trust Commercial |
$497.75
|
| Rate for Payer: WPS Commercial |
$321.16
|
|
|
Control of Nosebleed 3090350
|
Professional
|
$1,574.00
|
|
|
Service Code
|
CPT 30903 50
|
| Hospital Charge Code |
4294580
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.63 |
| Max. Negotiated Rate |
$1,495.30 |
| Rate for Payer: Aetna Commercial |
$1,495.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,353.64
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cash Price |
$472.20
|
| Rate for Payer: Cigna Commercial |
$1,495.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$787.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$944.40
|
| Rate for Payer: Health EOS Commercial |
$1,432.34
|
| Rate for Payer: Multiplan Commercial |
$1,259.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,495.30
|
| Rate for Payer: Quartz Beloit One Network |
$692.56
|
| Rate for Payer: Quartz Commercial |
$897.18
|
| Rate for Payer: The Alliance Commercial |
$787.00
|
| Rate for Payer: United Healthcare Medicaid |
$60.63
|
| Rate for Payer: WEA Trust Commercial |
$865.70
|
| Rate for Payer: WPS Commercial |
$1,165.86
|
|
|
CONTROL PUMP WITH IZ AMS 800 72404127
|
Facility
OP
|
$34,254.00
|
|
|
Service Code
|
HCPCS C1815
|
| Hospital Charge Code |
5385020
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,591.12 |
| Max. Negotiated Rate |
$31,513.68 |
| Rate for Payer: Aetna Commercial |
$30,828.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29,458.44
|
| Rate for Payer: Aetna Managed Medicare |
$9,591.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,265.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,127.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,441.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,154.62
|
| Rate for Payer: Cash Price |
$10,276.20
|
| Rate for Payer: Cigna Commercial |
$31,513.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,168.54
|
| Rate for Payer: Health EOS Commercial |
$30,486.06
|
| Rate for Payer: HFN Commercial |
$31,513.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,690.50
|
| Rate for Payer: Multiplan Commercial |
$27,403.20
|
| Rate for Payer: NAPHCARE Commercial |
$20,552.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31,513.68
|
| Rate for Payer: Quartz Beloit One Network |
$16,784.46
|
| Rate for Payer: Quartz Commercial |
$22,265.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20,552.40
|
| Rate for Payer: WEA Trust Commercial |
$18,839.70
|
| Rate for Payer: WPS Commercial |
$25,371.94
|
|
