|
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
|
$2,202.00
|
|
|
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 Retroperitoneal Abscess
|
Professional
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629816
|
| 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 Retroperitoneal Abscess
|
Facility
IP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241014
|
|
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 Retroperitoneal Abscess
|
Facility
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629816
|
| 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 Retroperitoneal Abscess
|
Facility
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629816
|
| 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 Retroperitoneal Abscess
|
Facility
OP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241014
|
|
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 Retroperitoneal Abscess
|
Professional
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241014
|
|
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 Subdiaphragm/Subphrenic
|
Professional
|
$2,162.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241016
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$108.89 |
| 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: 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 |
$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 |
$108.89
|
| Rate for Payer: Health EOS Commercial |
$1,967.42
|
| 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 |
$1,729.60
|
| 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: 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 |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$544.45
|
|
|
CT Drainage Subdiaphragm/Subphrenic
|
Facility
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241016
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$3,205.00 |
| 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 |
$6.44
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,189.10
|
| Rate for Payer: WPS Commercial |
$762.23
|
|
|
CT Drainage Subdiaphragm/Subphrenic
|
Facility
IP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241016
|
|
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 Subdiaphram/Subphrenic
|
Professional
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629818
|
| 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 Subdiaphram/Subphrenic
|
Facility
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629818
|
| 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 Subdiaphram/Subphrenic
|
Facility
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629818
|
| 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 Elbow w/ Contrast Bilateral
|
Facility
OP
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241024
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,148.56 |
| Max. Negotiated Rate |
$16,408.00 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.56
|
| 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 |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,076.50
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,666.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,461.20
|
| Rate for Payer: The Alliance Commercial |
$16,408.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Elbow w/ Contrast Bilateral
|
Facility
IP
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241024
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,009.98 |
| Max. Negotiated Rate |
$3,773.84 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,461.20
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Elbow w/ Contrast Bilateral
|
Professional
|
$8,358.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
629826
|
| Min. Negotiated Rate |
$202.41 |
| Max. Negotiated Rate |
$7,940.10 |
| Rate for Payer: Aetna Commercial |
$7,940.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,187.88
|
| Rate for Payer: Aetna Managed Medicare |
$202.41
|
| Rate for Payer: Anthem Medicare Advantage |
$202.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$202.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$202.41
|
| Rate for Payer: Cash Price |
$2,507.40
|
| Rate for Payer: Cash Price |
$2,507.40
|
| Rate for Payer: Cigna Commercial |
$7,940.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,179.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.41
|
| Rate for Payer: Health EOS Commercial |
$7,605.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$754.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$202.41
|
| Rate for Payer: Multiplan Commercial |
$6,686.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,940.10
|
| Rate for Payer: Quartz Beloit One Network |
$3,677.52
|
| Rate for Payer: Quartz Commercial |
$4,764.06
|
| Rate for Payer: Quartz Medicare Advantage |
$202.41
|
| Rate for Payer: The Alliance Commercial |
$769.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.41
|
| Rate for Payer: WEA Trust Commercial |
$4,596.90
|
| Rate for Payer: WPS Commercial |
$1,012.05
|
|
|
CT Elbow w/ Contrast Bilateral
|
Facility
IP
|
$8,358.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
629826
|
| Min. Negotiated Rate |
$4,095.42 |
| Max. Negotiated Rate |
$7,689.36 |
| Rate for Payer: Aetna Commercial |
$7,522.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,429.74
|
| Rate for Payer: Cash Price |
$2,507.40
|
| Rate for Payer: Cigna Commercial |
$7,689.36
|
| Rate for Payer: Health EOS Commercial |
$7,438.62
|
| Rate for Payer: HFN Commercial |
$7,689.36
|
| Rate for Payer: Multiplan Commercial |
$6,686.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,014.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,689.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,095.42
|
| Rate for Payer: Quartz Commercial |
$5,014.80
|
| Rate for Payer: WEA Trust Commercial |
$4,596.90
|
| Rate for Payer: WPS Commercial |
$6,190.77
|
|
|
CT Elbow w/ Contrast Bilateral
|
Professional
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241024
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,804.88 |
| Max. Negotiated Rate |
$3,896.90 |
| Rate for Payer: Aetna Commercial |
$3,896.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,896.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,051.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.20
|
| Rate for Payer: Health EOS Commercial |
$3,732.82
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,896.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,804.88
|
| Rate for Payer: Quartz Commercial |
$2,338.14
|
| Rate for Payer: The Alliance Commercial |
$2,051.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Elbow w/ Contrast Bilateral
|
Facility
OP
|
$8,358.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
629826
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$7,689.36 |
| Rate for Payer: Aetna Commercial |
$7,522.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,187.88
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,432.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,179.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,011.84
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,429.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$2,507.40
|
| Rate for Payer: Cash Price |
$2,507.40
|
| Rate for Payer: Cigna Commercial |
$7,689.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$7,438.62
|
| Rate for Payer: HFN Commercial |
$7,689.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$6,686.40
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$7,689.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,095.42
|
| Rate for Payer: Quartz Commercial |
$5,432.70
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,897.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: WEA Trust Commercial |
$4,596.90
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$6,190.77
|
|
|
CT Elbow w/ Contrast Left
|
Professional
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241026
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,804.88 |
| Max. Negotiated Rate |
$3,896.90 |
| Rate for Payer: Aetna Commercial |
$3,896.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,896.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,051.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,461.20
|
| Rate for Payer: Health EOS Commercial |
$3,732.82
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,896.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,804.88
|
| Rate for Payer: Quartz Commercial |
$2,338.14
|
| Rate for Payer: The Alliance Commercial |
$2,051.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Elbow w/ Contrast Left
|
Professional
|
$4,181.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
629828
|
| Min. Negotiated Rate |
$202.41 |
| Max. Negotiated Rate |
$3,971.95 |
| Rate for Payer: Aetna Commercial |
$3,971.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,595.66
|
| Rate for Payer: Aetna Managed Medicare |
$202.41
|
| Rate for Payer: Anthem Medicare Advantage |
$202.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$202.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$202.41
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,971.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,090.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.41
|
| Rate for Payer: Health EOS Commercial |
$3,804.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$754.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$202.41
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,971.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,839.64
|
| Rate for Payer: Quartz Commercial |
$2,383.17
|
| Rate for Payer: Quartz Medicare Advantage |
$202.41
|
| Rate for Payer: The Alliance Commercial |
$769.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$202.41
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$1,012.05
|
|
|
CT Elbow w/ Contrast Left
|
Facility
IP
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241026
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,009.98 |
| Max. Negotiated Rate |
$3,773.84 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,461.20
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
|
CT Elbow w/ Contrast Left
|
Facility
IP
|
$4,181.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
629828
|
| Min. Negotiated Rate |
$2,048.69 |
| Max. Negotiated Rate |
$3,846.52 |
| Rate for Payer: Aetna Commercial |
$3,762.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.93
|
| Rate for Payer: Cash Price |
$1,254.30
|
| Rate for Payer: Cigna Commercial |
$3,846.52
|
| Rate for Payer: Health EOS Commercial |
$3,721.09
|
| Rate for Payer: HFN Commercial |
$3,846.52
|
| Rate for Payer: Multiplan Commercial |
$3,344.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,508.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,846.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.69
|
| Rate for Payer: Quartz Commercial |
$2,508.60
|
| Rate for Payer: WEA Trust Commercial |
$2,299.55
|
| Rate for Payer: WPS Commercial |
$3,096.87
|
|
|
CT Elbow w/ Contrast Left
|
Facility
OP
|
$4,102.00
|
|
|
Service Code
|
CPT 73201 LT,TC
|
| Hospital Charge Code |
1241026
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,148.56 |
| Max. Negotiated Rate |
$16,408.00 |
| Rate for Payer: Aetna Commercial |
$3,691.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,527.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.56
|
| 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 |
$2,174.06
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cash Price |
$1,230.60
|
| Rate for Payer: Cigna Commercial |
$3,773.84
|
| Rate for Payer: Health EOS Commercial |
$3,650.78
|
| Rate for Payer: HFN Commercial |
$3,773.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,076.50
|
| Rate for Payer: Multiplan Commercial |
$3,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,773.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.98
|
| Rate for Payer: Quartz Commercial |
$2,666.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,461.20
|
| Rate for Payer: The Alliance Commercial |
$16,408.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,256.10
|
| Rate for Payer: WPS Commercial |
$3,038.35
|
|
