|
Dehydroepiandrosterone Sulfate
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
977925
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.56 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna Commercial |
$165.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$165.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.40
|
| Rate for Payer: Health EOS Commercial |
$158.34
|
| Rate for Payer: HFN Commercial |
$165.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.47
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$165.30
|
| Rate for Payer: Quartz Beloit One Network |
$76.56
|
| Rate for Payer: Quartz Commercial |
$99.18
|
| Rate for Payer: The Alliance Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Dehydroepiandrosterone Sulfate
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
977925
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Delatestryl 100 mg Charge
|
Professional
|
Both
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.80
|
| Rate for Payer: Health EOS Commercial |
$16.38
|
| Rate for Payer: HFN Commercial |
$17.10
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.10
|
| Rate for Payer: Quartz Beloit One Network |
$7.92
|
| Rate for Payer: Quartz Commercial |
$10.26
|
| Rate for Payer: The Alliance Commercial |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Delatestryl 100 mg Charge
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.07
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Delatestryl 100 mg Charge
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Delay Flap/SCTJ Flap Eyelids Nose Ears/Lips 15630
|
Professional
|
Both
|
$3,492.00
|
|
|
Service Code
|
CPT 15630
|
| Hospital Charge Code |
5082946
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$313.36 |
| Max. Negotiated Rate |
$3,317.40 |
| Rate for Payer: Aetna Commercial |
$3,317.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.12
|
| Rate for Payer: Cash Price |
$1,047.60
|
| Rate for Payer: Cash Price |
$1,047.60
|
| Rate for Payer: Cigna Commercial |
$3,317.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,095.20
|
| Rate for Payer: Health EOS Commercial |
$3,177.72
|
| Rate for Payer: HFN Commercial |
$3,317.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,140.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,140.30
|
| Rate for Payer: Multiplan Commercial |
$2,793.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,317.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.48
|
| Rate for Payer: Quartz Commercial |
$1,990.44
|
| Rate for Payer: The Alliance Commercial |
$1,746.00
|
| Rate for Payer: United Healthcare Medicaid |
$313.36
|
| Rate for Payer: WEA Trust Commercial |
$1,920.60
|
| Rate for Payer: WPS Commercial |
$2,586.52
|
|
|
DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS, OR LIPS
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
DELIVERY KIT INTRAOSSEOUS BIOPLASTY CORE DECOMPRESSION ABS-2000-OT
|
Facility
|
IP
|
$4,954.00
|
|
| Hospital Charge Code |
5458900
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,427.46 |
| Max. Negotiated Rate |
$4,557.68 |
| Rate for Payer: Aetna Commercial |
$4,458.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,260.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,625.62
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,557.68
|
| Rate for Payer: Health EOS Commercial |
$4,409.06
|
| Rate for Payer: HFN Commercial |
$4,557.68
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,972.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,557.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,427.46
|
| Rate for Payer: Quartz Commercial |
$2,972.40
|
| Rate for Payer: WEA Trust Commercial |
$2,724.70
|
| Rate for Payer: WPS Commercial |
$3,669.43
|
|
|
DELIVERY KIT INTRAOSSEOUS BIOPLASTY CORE DECOMPRESSION ABS-2000-OT
|
Facility
|
OP
|
$4,954.00
|
|
| Hospital Charge Code |
5458900
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,387.12 |
| Max. Negotiated Rate |
$19,816.00 |
| Rate for Payer: Aetna Commercial |
$4,458.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,260.44
|
| Rate for Payer: Aetna Managed Medicare |
$1,387.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,220.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,477.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,377.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,625.62
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,557.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,772.26
|
| Rate for Payer: Health EOS Commercial |
$4,409.06
|
| Rate for Payer: HFN Commercial |
$4,557.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,715.50
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,972.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,557.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,427.46
|
| Rate for Payer: Quartz Commercial |
$3,220.10
|
| Rate for Payer: Quartz Medicare Advantage |
$2,972.40
|
| Rate for Payer: The Alliance Commercial |
$19,816.00
|
| Rate for Payer: WEA Trust Commercial |
$2,724.70
|
| Rate for Payer: WPS Commercial |
$3,669.43
|
|
|
DELIVERY NEEDLE 8GA X 15CM OPEN TIP RAN-815-OT
|
Facility
|
OP
|
$2,046.00
|
|
| Hospital Charge Code |
5641629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$572.88 |
| Max. Negotiated Rate |
$8,184.00 |
| Rate for Payer: Aetna Commercial |
$1,841.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,759.56
|
| Rate for Payer: Aetna Managed Medicare |
$572.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,329.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,023.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$982.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,084.38
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,882.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,144.94
|
| Rate for Payer: Health EOS Commercial |
$1,820.94
|
| Rate for Payer: HFN Commercial |
$1,882.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,534.50
|
| Rate for Payer: Multiplan Commercial |
$1,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,227.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,882.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,002.54
|
| Rate for Payer: Quartz Commercial |
$1,329.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,227.60
|
| Rate for Payer: The Alliance Commercial |
$8,184.00
|
| Rate for Payer: WEA Trust Commercial |
$1,125.30
|
| Rate for Payer: WPS Commercial |
$1,515.47
|
|
|
DELIVERY NEEDLE 8GA X 15CM OPEN TIP RAN-815-OT
|
Facility
|
IP
|
$2,046.00
|
|
| Hospital Charge Code |
5641629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,002.54 |
| Max. Negotiated Rate |
$1,882.32 |
| Rate for Payer: Aetna Commercial |
$1,841.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,759.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,084.38
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,882.32
|
| Rate for Payer: Health EOS Commercial |
$1,820.94
|
| Rate for Payer: HFN Commercial |
$1,882.32
|
| Rate for Payer: Multiplan Commercial |
$1,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,227.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,882.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,002.54
|
| Rate for Payer: Quartz Commercial |
$1,227.60
|
| Rate for Payer: WEA Trust Commercial |
$1,125.30
|
| Rate for Payer: WPS Commercial |
$1,515.47
|
|
|
DELIVERY NEEDLE 8G X 11CM OPEN TIP RAN-811-OT
|
Facility
|
OP
|
$1,986.00
|
|
| Hospital Charge Code |
6210991
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$556.08 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$1,787.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,707.96
|
| Rate for Payer: Aetna Managed Medicare |
$556.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,290.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$993.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$953.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,052.58
|
| Rate for Payer: Cash Price |
$595.80
|
| Rate for Payer: Cigna Commercial |
$1,827.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,111.37
|
| Rate for Payer: Health EOS Commercial |
$1,767.54
|
| Rate for Payer: HFN Commercial |
$1,827.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,489.50
|
| Rate for Payer: Multiplan Commercial |
$1,588.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,191.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,827.12
|
| Rate for Payer: Quartz Beloit One Network |
$973.14
|
| Rate for Payer: Quartz Commercial |
$1,290.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,191.60
|
| Rate for Payer: The Alliance Commercial |
$7,944.00
|
| Rate for Payer: WEA Trust Commercial |
$1,092.30
|
| Rate for Payer: WPS Commercial |
$1,471.03
|
|
|
DELIVERY NEEDLE 8G X 11CM OPEN TIP RAN-811-OT
|
Facility
|
IP
|
$1,986.00
|
|
| Hospital Charge Code |
6210991
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$973.14 |
| Max. Negotiated Rate |
$1,827.12 |
| Rate for Payer: Aetna Commercial |
$1,787.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,707.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,052.58
|
| Rate for Payer: Cash Price |
$595.80
|
| Rate for Payer: Cigna Commercial |
$1,827.12
|
| Rate for Payer: Health EOS Commercial |
$1,767.54
|
| Rate for Payer: HFN Commercial |
$1,827.12
|
| Rate for Payer: Multiplan Commercial |
$1,588.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,191.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,827.12
|
| Rate for Payer: Quartz Beloit One Network |
$973.14
|
| Rate for Payer: Quartz Commercial |
$1,191.60
|
| Rate for Payer: WEA Trust Commercial |
$1,092.30
|
| Rate for Payer: WPS Commercial |
$1,471.03
|
|
|
DELIVERY NEEDLE NORIAN 10GA X 10CM DLS-7103-01S
|
Facility
|
IP
|
$806.00
|
|
| Hospital Charge Code |
3842758
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$394.94 |
| Max. Negotiated Rate |
$741.52 |
| Rate for Payer: Aetna Commercial |
$725.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$693.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.18
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$741.52
|
| Rate for Payer: Health EOS Commercial |
$717.34
|
| Rate for Payer: HFN Commercial |
$741.52
|
| Rate for Payer: Multiplan Commercial |
$644.80
|
| Rate for Payer: NAPHCARE Commercial |
$483.60
|
| Rate for Payer: Preferred Network Access Commercial |
$741.52
|
| Rate for Payer: Quartz Beloit One Network |
$394.94
|
| Rate for Payer: Quartz Commercial |
$483.60
|
| Rate for Payer: WEA Trust Commercial |
$443.30
|
| Rate for Payer: WPS Commercial |
$597.00
|
|
|
DELIVERY NEEDLE NORIAN 10GA X 10CM DLS-7103-01S
|
Facility
|
OP
|
$806.00
|
|
| Hospital Charge Code |
3842758
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.68 |
| Max. Negotiated Rate |
$3,224.00 |
| Rate for Payer: Aetna Commercial |
$725.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$693.16
|
| Rate for Payer: Aetna Managed Medicare |
$225.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$523.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$403.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$386.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$427.18
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$741.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$451.04
|
| Rate for Payer: Health EOS Commercial |
$717.34
|
| Rate for Payer: HFN Commercial |
$741.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$604.50
|
| Rate for Payer: Multiplan Commercial |
$644.80
|
| Rate for Payer: NAPHCARE Commercial |
$483.60
|
| Rate for Payer: Preferred Network Access Commercial |
$741.52
|
| Rate for Payer: Quartz Beloit One Network |
$394.94
|
| Rate for Payer: Quartz Commercial |
$523.90
|
| Rate for Payer: Quartz Medicare Advantage |
$483.60
|
| Rate for Payer: The Alliance Commercial |
$3,224.00
|
| Rate for Payer: WEA Trust Commercial |
$443.30
|
| Rate for Payer: WPS Commercial |
$597.00
|
|
|
Delta Aminolevulinic Acid 24 Hour Urine
|
Facility
|
OP
|
$62.25
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
977921
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$65.80 |
| Rate for Payer: Aetna Commercial |
$56.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.54
|
| Rate for Payer: Aetna Managed Medicare |
$16.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.31
|
| Rate for Payer: Anthem Medicaid |
$17.00
|
| Rate for Payer: Anthem Medicare Advantage |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.45
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.84
|
| Rate for Payer: Dean Health Medicaid |
$17.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.45
|
| Rate for Payer: Health EOS Commercial |
$55.40
|
| Rate for Payer: HFN Commercial |
$57.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.45
|
| Rate for Payer: Managed Health Services Medicaid |
$17.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.45
|
| Rate for Payer: Multiplan Commercial |
$49.80
|
| Rate for Payer: NAPHCARE Commercial |
$24.68
|
| Rate for Payer: Preferred Network Access Commercial |
$57.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.00
|
| Rate for Payer: Quartz Beloit One Network |
$30.50
|
| Rate for Payer: Quartz Commercial |
$40.46
|
| Rate for Payer: Quartz Medicare Advantage |
$16.45
|
| Rate for Payer: The Alliance Commercial |
$65.80
|
| Rate for Payer: United Healthcare Medicaid |
$17.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.45
|
| Rate for Payer: United Healthcare PPO |
$46.69
|
| Rate for Payer: WEA Trust Commercial |
$34.24
|
| Rate for Payer: Wellcare Medicare |
$16.45
|
| Rate for Payer: WMAP Medicaid |
$17.00
|
| Rate for Payer: WPS Commercial |
$46.11
|
|
|
Delta Aminolevulinic Acid 24 Hour Urine
|
Professional
|
Both
|
$62.25
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
977921
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.39 |
| Max. Negotiated Rate |
$59.14 |
| Rate for Payer: Aetna Commercial |
$59.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.54
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$59.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.35
|
| Rate for Payer: Health EOS Commercial |
$56.65
|
| Rate for Payer: HFN Commercial |
$59.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.07
|
| Rate for Payer: Multiplan Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$59.14
|
| Rate for Payer: Quartz Beloit One Network |
$27.39
|
| Rate for Payer: Quartz Commercial |
$35.48
|
| Rate for Payer: The Alliance Commercial |
$31.12
|
| Rate for Payer: WEA Trust Commercial |
$34.24
|
| Rate for Payer: WPS Commercial |
$46.11
|
|
|
Delta Aminolevulinic Acid 24 Hour Urine
|
Facility
|
IP
|
$62.25
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
977921
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$57.27 |
| Rate for Payer: Aetna Commercial |
$56.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.99
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: Health EOS Commercial |
$55.40
|
| Rate for Payer: HFN Commercial |
$57.27
|
| Rate for Payer: Multiplan Commercial |
$49.80
|
| Rate for Payer: NAPHCARE Commercial |
$37.35
|
| Rate for Payer: Preferred Network Access Commercial |
$57.27
|
| Rate for Payer: Quartz Beloit One Network |
$30.50
|
| Rate for Payer: Quartz Commercial |
$37.35
|
| Rate for Payer: WEA Trust Commercial |
$34.24
|
| Rate for Payer: WPS Commercial |
$46.11
|
|
|
Delta Aminolevulinic Acid, Urine
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Aetna Managed Medicare |
$16.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.31
|
| Rate for Payer: Anthem Medicaid |
$17.00
|
| Rate for Payer: Anthem Medicare Advantage |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.45
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.68
|
| Rate for Payer: Dean Health Medicaid |
$17.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.45
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.45
|
| Rate for Payer: Managed Health Services Medicaid |
$17.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.45
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$24.68
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.00
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$127.40
|
| Rate for Payer: Quartz Medicare Advantage |
$16.45
|
| Rate for Payer: The Alliance Commercial |
$65.80
|
| Rate for Payer: United Healthcare Medicaid |
$17.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.45
|
| Rate for Payer: United Healthcare PPO |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: Wellcare Medicare |
$16.45
|
| Rate for Payer: WMAP Medicaid |
$17.00
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Delta Aminolevulinic Acid, Urine
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.07 |
| Max. Negotiated Rate |
$186.20 |
| Rate for Payer: Aetna Commercial |
$186.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$186.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.60
|
| Rate for Payer: Health EOS Commercial |
$178.36
|
| Rate for Payer: HFN Commercial |
$186.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.07
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: Preferred Network Access Commercial |
$186.20
|
| Rate for Payer: Quartz Beloit One Network |
$86.24
|
| Rate for Payer: Quartz Commercial |
$111.72
|
| Rate for Payer: The Alliance Commercial |
$98.00
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
Delta Aminolevulinic Acid, Urine
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.04 |
| Max. Negotiated Rate |
$180.32 |
| Rate for Payer: Aetna Commercial |
$176.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.88
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$180.32
|
| Rate for Payer: Health EOS Commercial |
$174.44
|
| Rate for Payer: HFN Commercial |
$180.32
|
| Rate for Payer: Multiplan Commercial |
$156.80
|
| Rate for Payer: NAPHCARE Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$180.32
|
| Rate for Payer: Quartz Beloit One Network |
$96.04
|
| Rate for Payer: Quartz Commercial |
$117.60
|
| Rate for Payer: WEA Trust Commercial |
$107.80
|
| Rate for Payer: WPS Commercial |
$145.18
|
|
|
DELUXE SQUARE REBOUNDER
|
Facility
|
IP
|
$5,445.00
|
|
| Hospital Charge Code |
2973658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,668.05 |
| Max. Negotiated Rate |
$5,009.40 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,267.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
DELUXE SQUARE REBOUNDER
|
Facility
|
OP
|
$5,445.00
|
|
| Hospital Charge Code |
2973658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,524.60 |
| Max. Negotiated Rate |
$21,780.00 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,524.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,539.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,722.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,613.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,047.02
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,083.75
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,539.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,267.00
|
| Rate for Payer: The Alliance Commercial |
$21,780.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
Demerol 100 mg Charge
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2958935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.13
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$17.25
|
|
|
Demerol 100 mg Charge
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2958935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
