|
CT Drainage Pancreas
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629806
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$641.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,488.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,145.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,099.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,281.56
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,717.56
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,374.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,488.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,374.05
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
CT Drainage Pancreas
|
Facility
|
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Aetna Managed Medicare |
$629.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| 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 |
$2,068.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,258.28
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,686.36
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,349.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,461.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,349.09
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$782.67
|
|
|
CT Drainage Pancreas
|
Facility
|
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629806
|
| Min. Negotiated Rate |
$1,122.14 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,374.05
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
CT Drainage Pancreas
|
Professional
|
Both
|
$2,162.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$111.81 |
| Max. Negotiated Rate |
$2,136.06 |
| Rate for Payer: Aetna Commercial |
$2,136.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Aetna Managed Medicare |
$111.81
|
| Rate for Payer: Anthem Medicare Advantage |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.81
|
| 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 |
$2,136.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,124.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.81
|
| Rate for Payer: Health EOS Commercial |
$2,046.12
|
| Rate for Payer: HFN Commercial |
$2,136.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.81
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: NAPHCARE Commercial |
$167.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,136.06
|
| Rate for Payer: Quartz Beloit One Network |
$989.33
|
| Rate for Payer: Quartz Commercial |
$1,281.63
|
| Rate for Payer: Quartz Medicare Advantage |
$111.81
|
| Rate for Payer: The Alliance Commercial |
$424.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.81
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$559.05
|
|
|
CT Drainage Peritoneal
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$111.81 |
| Max. Negotiated Rate |
$2,223.00 |
| Rate for Payer: Aetna Commercial |
$2,223.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,012.40
|
| Rate for Payer: Aetna Managed Medicare |
$111.81
|
| Rate for Payer: Anthem Medicare Advantage |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.81
|
| 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 |
$2,223.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,170.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.81
|
| Rate for Payer: Health EOS Commercial |
$2,129.40
|
| Rate for Payer: HFN Commercial |
$2,223.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.81
|
| Rate for Payer: Multiplan Commercial |
$1,872.00
|
| Rate for Payer: NAPHCARE Commercial |
$167.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,223.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,029.60
|
| Rate for Payer: Quartz Commercial |
$1,333.80
|
| Rate for Payer: Quartz Medicare Advantage |
$111.81
|
| Rate for Payer: The Alliance Commercial |
$424.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.81
|
| Rate for Payer: WEA Trust Commercial |
$1,287.00
|
| Rate for Payer: WPS Commercial |
$559.05
|
|
|
CT Drainage Peritoneal
|
Facility
|
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$1,122.14 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,374.05
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
CT Drainage Peritoneal
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,106.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,012.40
|
| Rate for Payer: Aetna Managed Medicare |
$655.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,240.20
|
| 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 |
$2,152.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,309.50
|
| Rate for Payer: Health EOS Commercial |
$2,082.60
|
| Rate for Payer: HFN Commercial |
$2,152.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,755.00
|
| Rate for Payer: Multiplan Commercial |
$1,872.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,404.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,152.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,146.60
|
| Rate for Payer: Quartz Commercial |
$1,521.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,404.00
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,287.00
|
| Rate for Payer: WPS Commercial |
$782.67
|
|
|
CT Drainage Peritoneal
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
1241006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,146.60 |
| Max. Negotiated Rate |
$2,152.80 |
| Rate for Payer: Aetna Commercial |
$2,106.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,012.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,240.20
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$2,152.80
|
| Rate for Payer: Health EOS Commercial |
$2,082.60
|
| Rate for Payer: HFN Commercial |
$2,152.80
|
| Rate for Payer: Multiplan Commercial |
$1,872.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,152.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,146.60
|
| Rate for Payer: Quartz Commercial |
$1,404.00
|
| Rate for Payer: WEA Trust Commercial |
$1,287.00
|
| Rate for Payer: WPS Commercial |
$1,733.17
|
|
|
CT Drainage Peritoneal
|
Professional
|
Both
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$111.81 |
| Max. Negotiated Rate |
$2,175.58 |
| Rate for Payer: Aetna Commercial |
$2,175.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$111.81
|
| Rate for Payer: Anthem Medicare Advantage |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.81
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,175.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,145.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.81
|
| Rate for Payer: Health EOS Commercial |
$2,083.97
|
| Rate for Payer: HFN Commercial |
$2,175.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.81
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$167.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.64
|
| Rate for Payer: Quartz Commercial |
$1,305.35
|
| Rate for Payer: Quartz Medicare Advantage |
$111.81
|
| Rate for Payer: The Alliance Commercial |
$424.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.81
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$559.05
|
|
|
CT Drainage Peritoneal
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629808
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$641.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,488.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,145.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,099.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,281.56
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,717.56
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,374.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,488.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,374.05
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
CT Drainage Renal Bilateral
|
Professional
|
Both
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$111.81 |
| Max. Negotiated Rate |
$4,353.13 |
| Rate for Payer: Aetna Commercial |
$4,353.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,940.73
|
| Rate for Payer: Aetna Managed Medicare |
$111.81
|
| Rate for Payer: Anthem Medicare Advantage |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.81
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,353.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,291.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.81
|
| Rate for Payer: Health EOS Commercial |
$4,169.84
|
| Rate for Payer: HFN Commercial |
$4,353.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.81
|
| Rate for Payer: Multiplan Commercial |
$3,665.79
|
| Rate for Payer: NAPHCARE Commercial |
$167.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,353.13
|
| Rate for Payer: Quartz Beloit One Network |
$2,016.19
|
| Rate for Payer: Quartz Commercial |
$2,611.88
|
| Rate for Payer: Quartz Medicare Advantage |
$111.81
|
| Rate for Payer: The Alliance Commercial |
$424.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.81
|
| Rate for Payer: WEA Trust Commercial |
$2,520.23
|
| Rate for Payer: WPS Commercial |
$559.05
|
|
|
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 |
$1,101.76 |
| Max. Negotiated Rate |
$2,068.60 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$2,068.60
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,349.09
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Bilateral
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$2,245.30 |
| Max. Negotiated Rate |
$4,215.66 |
| Rate for Payer: Aetna Commercial |
$4,124.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,940.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,428.59
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,215.66
|
| Rate for Payer: Health EOS Commercial |
$4,078.19
|
| Rate for Payer: HFN Commercial |
$4,215.66
|
| Rate for Payer: Multiplan Commercial |
$3,665.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,215.66
|
| Rate for Payer: Quartz Beloit One Network |
$2,245.30
|
| Rate for Payer: Quartz Commercial |
$2,749.34
|
| Rate for Payer: WEA Trust Commercial |
$2,520.23
|
| Rate for Payer: WPS Commercial |
$3,393.94
|
|
|
CT Drainage Renal Bilateral
|
Professional
|
Both
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241008
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$423.00 |
| Max. Negotiated Rate |
$2,136.06 |
| Rate for Payer: Aetna Commercial |
$2,136.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| 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 |
$2,136.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,124.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,349.09
|
| Rate for Payer: Health EOS Commercial |
$2,046.12
|
| Rate for Payer: HFN Commercial |
$2,136.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,136.06
|
| Rate for Payer: Quartz Beloit One Network |
$989.33
|
| Rate for Payer: Quartz Commercial |
$1,281.63
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
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 |
$629.57 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Aetna Managed Medicare |
$629.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| 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 |
$2,068.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,258.28
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,686.36
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,349.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,461.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,349.09
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Bilateral
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629810
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$4,215.66 |
| Rate for Payer: Aetna Commercial |
$4,124.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,940.73
|
| Rate for Payer: Aetna Managed Medicare |
$1,283.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,978.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,291.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,199.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,428.59
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cash Price |
$1,321.80
|
| Rate for Payer: Cigna Commercial |
$4,215.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,564.29
|
| Rate for Payer: Health EOS Commercial |
$4,078.19
|
| Rate for Payer: HFN Commercial |
$4,215.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,436.68
|
| Rate for Payer: Multiplan Commercial |
$3,665.79
|
| Rate for Payer: NAPHCARE Commercial |
$2,749.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,215.66
|
| Rate for Payer: Quartz Beloit One Network |
$2,245.30
|
| Rate for Payer: Quartz Commercial |
$2,978.46
|
| Rate for Payer: Quartz Medicare Advantage |
$2,749.34
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: WEA Trust Commercial |
$2,520.23
|
| Rate for Payer: WPS Commercial |
$3,393.94
|
|
|
CT Drainage Renal Left
|
Professional
|
Both
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 LT
|
| Hospital Charge Code |
1241010
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$423.00 |
| Max. Negotiated Rate |
$2,136.06 |
| Rate for Payer: Aetna Commercial |
$2,136.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| 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 |
$2,136.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,124.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,349.09
|
| Rate for Payer: Health EOS Commercial |
$2,046.12
|
| Rate for Payer: HFN Commercial |
$2,136.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,136.06
|
| Rate for Payer: Quartz Beloit One Network |
$989.33
|
| Rate for Payer: Quartz Commercial |
$1,281.63
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Left
|
Facility
|
IP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$1,122.14 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,374.05
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
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 |
$1,101.76 |
| Max. Negotiated Rate |
$2,068.60 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| Rate for Payer: Cash Price |
$648.60
|
| Rate for Payer: Cigna Commercial |
$2,068.60
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,349.09
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Left
|
Professional
|
Both
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$111.81 |
| Max. Negotiated Rate |
$2,175.58 |
| Rate for Payer: Aetna Commercial |
$2,175.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$111.81
|
| Rate for Payer: Anthem Medicare Advantage |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.81
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,175.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,145.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.81
|
| Rate for Payer: Health EOS Commercial |
$2,083.97
|
| Rate for Payer: HFN Commercial |
$2,175.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.81
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$167.72
|
| Rate for Payer: Preferred Network Access Commercial |
$2,175.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,007.64
|
| Rate for Payer: Quartz Commercial |
$1,305.35
|
| Rate for Payer: Quartz Medicare Advantage |
$111.81
|
| Rate for Payer: The Alliance Commercial |
$424.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.81
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$559.05
|
|
|
CT Drainage Renal Left
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629812
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$641.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,488.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,145.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,099.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,281.56
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,717.56
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,374.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,488.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,374.05
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
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 |
$629.57 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Aetna Managed Medicare |
$629.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| 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 |
$2,068.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,258.28
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,686.36
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,349.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,461.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,349.09
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Right
|
Professional
|
Both
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 RT
|
| Hospital Charge Code |
1241012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$423.00 |
| Max. Negotiated Rate |
$2,136.06 |
| Rate for Payer: Aetna Commercial |
$2,136.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| 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 |
$2,136.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,124.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,349.09
|
| Rate for Payer: Health EOS Commercial |
$2,046.12
|
| Rate for Payer: HFN Commercial |
$2,136.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.00
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,136.06
|
| Rate for Payer: Quartz Beloit One Network |
$989.33
|
| Rate for Payer: Quartz Commercial |
$1,281.63
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
|
CT Drainage Renal Right
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
CPT 75989
|
| Hospital Charge Code |
629814
|
| Min. Negotiated Rate |
$447.24 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$641.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,488.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,145.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,099.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,281.56
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,717.56
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,374.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,488.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,374.05
|
| Rate for Payer: The Alliance Commercial |
$447.24
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
CT Drainage Renal Right
|
Facility
|
OP
|
$2,162.00
|
|
|
Service Code
|
CPT 75989 TC,RT
|
| Hospital Charge Code |
2980115
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$629.57 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$2,023.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,933.69
|
| Rate for Payer: Aetna Managed Medicare |
$629.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,191.69
|
| 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 |
$2,068.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,258.28
|
| Rate for Payer: Health EOS Commercial |
$2,001.15
|
| Rate for Payer: HFN Commercial |
$2,068.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,686.36
|
| Rate for Payer: Multiplan Commercial |
$1,798.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,349.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,068.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,101.76
|
| Rate for Payer: Quartz Commercial |
$1,461.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,349.09
|
| Rate for Payer: The Alliance Commercial |
$1,124.24
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$1,236.66
|
| Rate for Payer: WPS Commercial |
$1,665.39
|
|
