|
CT Drainage Peritoneal
|
Professional
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$108.89 |
| Max. Negotiated Rate |
$2,091.90 |
| Rate for Payer: Aetna Commercial |
$2,091.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$108.89
|
| Rate for Payer: Anthem Medicare Advantage |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.89
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,091.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,101.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$2,003.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.89
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,091.90
|
| Rate for Payer: Quartz Beloit One Network |
$968.88
|
| Rate for Payer: Quartz Commercial |
$1,255.14
|
| Rate for Payer: Quartz Medicare Advantage |
$108.89
|
| Rate for Payer: The Alliance Commercial |
$413.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.89
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Peritoneal
|
Facility
OP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$3,205.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Aetna Managed Medicare |
$630.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,462.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,350.00
|
| Rate for Payer: The Alliance Commercial |
$6.44
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$762.23
|
|
|
CT Drainage Peritoneal
|
Facility
IP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,102.50 |
| Max. Negotiated Rate |
$2,070.00 |
| Rate for Payer: Aetna Commercial |
$2,025.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,192.50
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,070.00
|
| Rate for Payer: Health EOS Commercial |
$2,002.50
|
| Rate for Payer: HFN Commercial |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.50
|
| Rate for Payer: Quartz Commercial |
$1,350.00
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$1,666.58
|
|
|
CT Drainage Peritoneal
|
Professional
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$108.89 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Aetna Commercial |
$2,137.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.00
|
| Rate for Payer: Aetna Managed Medicare |
$108.89
|
| Rate for Payer: Anthem Medicare Advantage |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.89
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,137.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,125.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$2,047.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.89
|
| Rate for Payer: Multiplan Commercial |
$1,800.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,137.50
|
| Rate for Payer: Quartz Beloit One Network |
$990.00
|
| Rate for Payer: Quartz Commercial |
$1,282.50
|
| Rate for Payer: Quartz Medicare Advantage |
$108.89
|
| Rate for Payer: The Alliance Commercial |
$413.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.89
|
| Rate for Payer: WEA Trust Commercial |
$1,237.50
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Peritoneal
|
Facility
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$1,078.98 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,321.20
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
CT Drainage Peritoneal
|
Facility
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$616.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,431.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,056.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,651.50
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,431.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,321.20
|
| Rate for Payer: The Alliance Commercial |
$6.44
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
CT Drainage Renal Bilateral
|
Facility
IP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241008
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Bilateral
|
Facility
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241008
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$605.36 |
| Max. Negotiated Rate |
$8,648.00 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Aetna Managed Medicare |
$605.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,621.50
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,405.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,297.20
|
| Rate for Payer: The Alliance Commercial |
$8,648.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Bilateral
|
Facility
OP
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$4,053.52 |
| Rate for Payer: Aetna Commercial |
$3,965.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,789.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,233.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,863.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,114.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,335.18
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,053.52
|
| Rate for Payer: Health EOS Commercial |
$3,921.34
|
| Rate for Payer: HFN Commercial |
$4,053.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,304.50
|
| Rate for Payer: Multiplan Commercial |
$3,524.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,053.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,158.94
|
| Rate for Payer: Quartz Commercial |
$2,863.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,643.60
|
| Rate for Payer: The Alliance Commercial |
$6.44
|
| Rate for Payer: WEA Trust Commercial |
$2,423.30
|
| Rate for Payer: WPS Commercial |
$3,263.52
|
|
|
CT Drainage Renal Bilateral
|
Professional
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241008
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$951.28 |
| Max. Negotiated Rate |
$2,053.90 |
| Rate for Payer: Aetna Commercial |
$2,053.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$2,053.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,081.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.20
|
| Rate for Payer: Health EOS Commercial |
$1,967.42
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,053.90
|
| Rate for Payer: Quartz Beloit One Network |
$951.28
|
| Rate for Payer: Quartz Commercial |
$1,232.34
|
| Rate for Payer: The Alliance Commercial |
$1,081.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Bilateral
|
Facility
IP
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$2,158.94 |
| Max. Negotiated Rate |
$4,053.52 |
| Rate for Payer: Aetna Commercial |
$3,965.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,335.18
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,053.52
|
| Rate for Payer: Health EOS Commercial |
$3,921.34
|
| Rate for Payer: HFN Commercial |
$4,053.52
|
| Rate for Payer: Multiplan Commercial |
$3,524.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,053.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,158.94
|
| Rate for Payer: Quartz Commercial |
$2,643.60
|
| Rate for Payer: WEA Trust Commercial |
$2,423.30
|
| Rate for Payer: WPS Commercial |
$3,263.52
|
|
|
CT Drainage Renal Bilateral
|
Professional
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$108.89 |
| Max. Negotiated Rate |
$4,185.70 |
| Rate for Payer: Aetna Commercial |
$4,185.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,789.16
|
| Rate for Payer: Aetna Managed Medicare |
$108.89
|
| Rate for Payer: Anthem Medicare Advantage |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.89
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,185.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,203.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$4,009.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.89
|
| Rate for Payer: Multiplan Commercial |
$3,524.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,185.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,938.64
|
| Rate for Payer: Quartz Commercial |
$2,511.42
|
| Rate for Payer: Quartz Medicare Advantage |
$108.89
|
| Rate for Payer: The Alliance Commercial |
$413.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.89
|
| Rate for Payer: WEA Trust Commercial |
$2,423.30
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Renal Left
|
Facility
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$616.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,431.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,056.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,651.50
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,431.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,321.20
|
| Rate for Payer: The Alliance Commercial |
$6.44
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
CT Drainage Renal Left
|
Facility
IP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241010
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Left
|
Professional
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241010
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$951.28 |
| Max. Negotiated Rate |
$2,053.90 |
| Rate for Payer: Aetna Commercial |
$2,053.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$2,053.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,081.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.20
|
| Rate for Payer: Health EOS Commercial |
$1,967.42
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,053.90
|
| Rate for Payer: Quartz Beloit One Network |
$951.28
|
| Rate for Payer: Quartz Commercial |
$1,232.34
|
| Rate for Payer: The Alliance Commercial |
$1,081.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Left
|
Facility
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241010
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$605.36 |
| Max. Negotiated Rate |
$8,648.00 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Aetna Managed Medicare |
$605.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,621.50
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,405.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,297.20
|
| Rate for Payer: The Alliance Commercial |
$8,648.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Left
|
Facility
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$1,078.98 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,321.20
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
CT Drainage Renal Left
|
Professional
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$108.89 |
| Max. Negotiated Rate |
$2,091.90 |
| Rate for Payer: Aetna Commercial |
$2,091.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$108.89
|
| Rate for Payer: Anthem Medicare Advantage |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.89
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,091.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,101.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$2,003.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.89
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,091.90
|
| Rate for Payer: Quartz Beloit One Network |
$968.88
|
| Rate for Payer: Quartz Commercial |
$1,255.14
|
| Rate for Payer: Quartz Medicare Advantage |
$108.89
|
| Rate for Payer: The Alliance Commercial |
$413.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.89
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Renal Right
|
Facility
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629814
|
| Min. Negotiated Rate |
$1,078.98 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,321.20
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
CT Drainage Renal Right
|
Facility
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 RT
|
| Hospital Charge Code |
1241012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$605.36 |
| Max. Negotiated Rate |
$8,648.00 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Aetna Managed Medicare |
$605.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,621.50
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,405.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,297.20
|
| Rate for Payer: The Alliance Commercial |
$8,648.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Right
|
Professional
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 RT
|
| Hospital Charge Code |
1241012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$951.28 |
| Max. Negotiated Rate |
$2,053.90 |
| Rate for Payer: Aetna Commercial |
$2,053.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,859.32
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$2,053.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,081.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,297.20
|
| Rate for Payer: Health EOS Commercial |
$1,967.42
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,053.90
|
| Rate for Payer: Quartz Beloit One Network |
$951.28
|
| Rate for Payer: Quartz Commercial |
$1,232.34
|
| Rate for Payer: The Alliance Commercial |
$1,081.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Right
|
Facility
IP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 RT
|
| Hospital Charge Code |
1241012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Right
|
Professional
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629814
|
| Min. Negotiated Rate |
$108.89 |
| Max. Negotiated Rate |
$2,091.90 |
| Rate for Payer: Aetna Commercial |
$2,091.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$108.89
|
| Rate for Payer: Anthem Medicare Advantage |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.89
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,091.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,101.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$2,003.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$406.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$406.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.89
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,091.90
|
| Rate for Payer: Quartz Beloit One Network |
$968.88
|
| Rate for Payer: Quartz Commercial |
$1,255.14
|
| Rate for Payer: Quartz Medicare Advantage |
$108.89
|
| Rate for Payer: The Alliance Commercial |
$413.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.89
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Renal Right
|
Facility
IP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 TC,RT
|
| Hospital Charge Code |
2980115
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,059.38 |
| Max. Negotiated Rate |
$1,989.04 |
| Rate for Payer: Aetna Commercial |
$1,945.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.86
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$1,989.04
|
| Rate for Payer: Health EOS Commercial |
$1,924.18
|
| Rate for Payer: HFN Commercial |
$1,989.04
|
| Rate for Payer: Multiplan Commercial |
$1,729.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,297.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,989.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,059.38
|
| Rate for Payer: Quartz Commercial |
$1,297.20
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$1,601.39
|
|
|
CT Drainage Renal Right
|
Facility
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629814
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$616.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,431.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,056.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,651.50
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,431.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,321.20
|
| Rate for Payer: The Alliance Commercial |
$6.44
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
