|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$34.32 |
| Max. Negotiated Rate |
$130.65 |
| Rate for Payer: Aetna Commercial |
$74.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.80
|
| Rate for Payer: Health EOS Commercial |
$70.98
|
| Rate for Payer: HFN Commercial |
$74.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.65
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$74.10
|
| Rate for Payer: Quartz Beloit One Network |
$34.32
|
| Rate for Payer: Quartz Commercial |
$44.46
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Diab Manage Trn Per Indiv G0108
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
5454715
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$189.24 |
| Rate for Payer: Aetna Commercial |
$110.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.60
|
| Rate for Payer: Health EOS Commercial |
$105.56
|
| Rate for Payer: HFN Commercial |
$110.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$189.24
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: Preferred Network Access Commercial |
$110.20
|
| Rate for Payer: Quartz Beloit One Network |
$51.04
|
| Rate for Payer: Quartz Commercial |
$66.12
|
| Rate for Payer: The Alliance Commercial |
$58.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
Diab shoe for density insert A5500
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Diab shoe for density insert A5500
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Diab shoe for density insert A5500
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS A5500
|
| Hospital Charge Code |
3133657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$261.29 |
| Rate for Payer: Aetna Commercial |
$93.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.80
|
| Rate for Payer: Health EOS Commercial |
$89.18
|
| Rate for Payer: HFN Commercial |
$93.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$261.29
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: Preferred Network Access Commercial |
$93.10
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$55.86
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Diagnostic - Bronchoscopy Charge
|
Facility
|
OP
|
$4,168.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
2990189
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,677.59 |
| Max. Negotiated Rate |
$6,240.63 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,677.59
|
| 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 |
$1,677.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,677.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,677.59
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,677.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,677.59
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,240.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,677.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,677.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,677.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,677.59
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,516.38
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,709.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,677.59
|
| Rate for Payer: The Alliance Commercial |
$2,851.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,677.59
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: Wellcare Medicare |
$1,677.59
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
Diagnostic - Bronchoscopy Charge
|
Facility
|
IP
|
$4,168.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
2990189
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,042.32 |
| Max. Negotiated Rate |
$3,834.56 |
| Rate for Payer: Aetna Commercial |
$3,751.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,584.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,209.04
|
| Rate for Payer: Cash Price |
$1,250.40
|
| Rate for Payer: Cigna Commercial |
$3,834.56
|
| Rate for Payer: Health EOS Commercial |
$3,709.52
|
| Rate for Payer: HFN Commercial |
$3,834.56
|
| Rate for Payer: Multiplan Commercial |
$3,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,834.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,042.32
|
| Rate for Payer: Quartz Commercial |
$2,500.80
|
| Rate for Payer: WEA Trust Commercial |
$2,292.40
|
| Rate for Payer: WPS Commercial |
$3,087.24
|
|
|
DIAGNOSTIC COLONOSCOPY 45378
|
Professional
|
Both
|
$2,188.00
|
|
|
Service Code
|
CPT 45378
|
| Hospital Charge Code |
3014805
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$344.79 |
| Max. Negotiated Rate |
$2,078.60 |
| Rate for Payer: Aetna Commercial |
$2,078.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,881.68
|
| Rate for Payer: Cash Price |
$656.40
|
| Rate for Payer: Cash Price |
$656.40
|
| Rate for Payer: Cigna Commercial |
$2,078.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$344.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,312.80
|
| Rate for Payer: Health EOS Commercial |
$1,991.08
|
| Rate for Payer: HFN Commercial |
$2,078.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$617.22
|
| Rate for Payer: Multiplan Commercial |
$1,750.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,078.60
|
| Rate for Payer: Quartz Beloit One Network |
$962.72
|
| Rate for Payer: Quartz Commercial |
$1,247.16
|
| Rate for Payer: The Alliance Commercial |
$1,094.00
|
| Rate for Payer: United Healthcare Medicaid |
$344.79
|
| Rate for Payer: WEA Trust Commercial |
$1,203.40
|
| Rate for Payer: WPS Commercial |
$1,620.65
|
|
|
DIAGNOSTIC COLONOSCOPY, EXTENDED 4537822
|
Professional
|
Both
|
$2,626.00
|
|
|
Service Code
|
CPT 45378 22
|
| Hospital Charge Code |
6178511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,155.44 |
| Max. Negotiated Rate |
$2,494.70 |
| Rate for Payer: Aetna Commercial |
$2,494.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,258.36
|
| Rate for Payer: Cash Price |
$787.80
|
| Rate for Payer: Cash Price |
$787.80
|
| Rate for Payer: Cigna Commercial |
$2,494.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,313.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,575.60
|
| Rate for Payer: Health EOS Commercial |
$2,389.66
|
| Rate for Payer: HFN Commercial |
$2,494.70
|
| Rate for Payer: Multiplan Commercial |
$2,100.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,494.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,155.44
|
| Rate for Payer: Quartz Commercial |
$1,496.82
|
| Rate for Payer: The Alliance Commercial |
$1,313.00
|
| Rate for Payer: WEA Trust Commercial |
$1,444.30
|
| Rate for Payer: WPS Commercial |
$1,945.08
|
|
|
Diagnostic Evaluation (No Medical) 90791
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
CPT 90791
|
| Hospital Charge Code |
2990616
|
|
Hospital Revenue Code
|
513
|
| Min. Negotiated Rate |
$246.40 |
| Max. Negotiated Rate |
$536.10 |
| Rate for Payer: Aetna Commercial |
$532.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.60
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$532.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$280.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.00
|
| Rate for Payer: Health EOS Commercial |
$509.60
|
| Rate for Payer: HFN Commercial |
$532.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$536.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$536.10
|
| Rate for Payer: Multiplan Commercial |
$448.00
|
| Rate for Payer: Preferred Network Access Commercial |
$532.00
|
| Rate for Payer: Quartz Beloit One Network |
$246.40
|
| Rate for Payer: Quartz Commercial |
$319.20
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$308.00
|
| Rate for Payer: WPS Commercial |
$414.79
|
|
|
Diagnostic OAE
|
Professional
|
Both
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$77.96 |
| Max. Negotiated Rate |
$505.40 |
| Rate for Payer: Aetna Commercial |
$505.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$505.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$319.20
|
| Rate for Payer: Health EOS Commercial |
$484.12
|
| Rate for Payer: HFN Commercial |
$505.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$117.20
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: Preferred Network Access Commercial |
$505.40
|
| Rate for Payer: Quartz Beloit One Network |
$234.08
|
| Rate for Payer: Quartz Commercial |
$303.24
|
| Rate for Payer: The Alliance Commercial |
$266.00
|
| Rate for Payer: United Healthcare Medicaid |
$77.96
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
Diagnostic OAE
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$255.36 |
| Max. Negotiated Rate |
$1,240.96 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Aetna Managed Medicare |
$310.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$345.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.36
|
| Rate for Payer: Anthem Medicare Advantage |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$310.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$310.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$310.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$310.24
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$310.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$310.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$310.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$310.24
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$465.36
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$345.80
|
| Rate for Payer: Quartz Medicare Advantage |
$310.24
|
| Rate for Payer: The Alliance Commercial |
$1,240.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$310.24
|
| Rate for Payer: United Healthcare PPO |
$399.00
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: Wellcare Medicare |
$310.24
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
Diagnostic OAE
|
Facility
|
IP
|
$532.00
|
|
|
Service Code
|
CPT 92588
|
| Hospital Charge Code |
3203489
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$260.68 |
| Max. Negotiated Rate |
$489.44 |
| Rate for Payer: Aetna Commercial |
$478.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$457.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$281.96
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$489.44
|
| Rate for Payer: Health EOS Commercial |
$473.48
|
| Rate for Payer: HFN Commercial |
$489.44
|
| Rate for Payer: Multiplan Commercial |
$425.60
|
| Rate for Payer: NAPHCARE Commercial |
$319.20
|
| Rate for Payer: Preferred Network Access Commercial |
$489.44
|
| Rate for Payer: Quartz Beloit One Network |
$260.68
|
| Rate for Payer: Quartz Commercial |
$319.20
|
| Rate for Payer: WEA Trust Commercial |
$292.60
|
| Rate for Payer: WPS Commercial |
$394.05
|
|
|
Diagnostic Sigmoidoscopy 45330
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 45330
|
| Hospital Charge Code |
3983432
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.21 |
| Max. Negotiated Rate |
$437.95 |
| Rate for Payer: Aetna Commercial |
$437.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$437.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$276.60
|
| Rate for Payer: Health EOS Commercial |
$419.51
|
| Rate for Payer: HFN Commercial |
$437.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$185.22
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: Preferred Network Access Commercial |
$437.95
|
| Rate for Payer: Quartz Beloit One Network |
$202.84
|
| Rate for Payer: Quartz Commercial |
$262.77
|
| Rate for Payer: The Alliance Commercial |
$230.50
|
| Rate for Payer: United Healthcare Medicaid |
$67.21
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
Dialysis Circuit Angio
|
Facility
|
IP
|
$2,380.00
|
|
|
Service Code
|
CPT 36901
|
| Hospital Charge Code |
5218689
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,166.20 |
| Max. Negotiated Rate |
$2,189.60 |
| Rate for Payer: Aetna Commercial |
$2,142.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.40
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Cigna Commercial |
$2,189.60
|
| Rate for Payer: Health EOS Commercial |
$2,118.20
|
| Rate for Payer: HFN Commercial |
$2,189.60
|
| Rate for Payer: Multiplan Commercial |
$1,904.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,428.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,166.20
|
| Rate for Payer: Quartz Commercial |
$1,428.00
|
| Rate for Payer: WEA Trust Commercial |
$1,309.00
|
| Rate for Payer: WPS Commercial |
$1,762.87
|
|
|
Dialysis Circuit Angio
|
Facility
|
OP
|
$2,380.00
|
|
|
Service Code
|
CPT 36901
|
| Hospital Charge Code |
5218689
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,166.20 |
| Max. Negotiated Rate |
$6,331.88 |
| Rate for Payer: Aetna Commercial |
$2,142.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,046.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,582.97
|
| 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 |
$1,582.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,261.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,582.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,582.97
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Cigna Commercial |
$2,189.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,582.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,582.97
|
| Rate for Payer: Health EOS Commercial |
$2,118.20
|
| Rate for Payer: HFN Commercial |
$2,189.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,888.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,582.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,582.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,582.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,582.97
|
| Rate for Payer: Multiplan Commercial |
$1,904.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,374.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,189.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,166.20
|
| Rate for Payer: Quartz Commercial |
$1,547.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,582.97
|
| Rate for Payer: The Alliance Commercial |
$6,331.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,582.97
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: WEA Trust Commercial |
$1,309.00
|
| Rate for Payer: Wellcare Medicare |
$1,582.97
|
| Rate for Payer: WPS Commercial |
$1,762.87
|
|
|
Dialysis Circuit Central PTA
|
Facility
|
IP
|
$1,370.00
|
|
|
Service Code
|
CPT 36907
|
| Hospital Charge Code |
5218695
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$671.30 |
| Max. Negotiated Rate |
$1,260.40 |
| Rate for Payer: Aetna Commercial |
$1,233.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,178.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$726.10
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$1,260.40
|
| Rate for Payer: Health EOS Commercial |
$1,219.30
|
| Rate for Payer: HFN Commercial |
$1,260.40
|
| Rate for Payer: Multiplan Commercial |
$1,096.00
|
| Rate for Payer: NAPHCARE Commercial |
$822.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,260.40
|
| Rate for Payer: Quartz Beloit One Network |
$671.30
|
| Rate for Payer: Quartz Commercial |
$822.00
|
| Rate for Payer: WEA Trust Commercial |
$753.50
|
| Rate for Payer: WPS Commercial |
$1,014.76
|
|
|
Dialysis Circuit Central PTA
|
Facility
|
OP
|
$1,370.00
|
|
|
Service Code
|
CPT 36907
|
| Hospital Charge Code |
5218695
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$383.60 |
| Max. Negotiated Rate |
$11,874.87 |
| Rate for Payer: Aetna Commercial |
$1,233.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,178.20
|
| Rate for Payer: Aetna Managed Medicare |
$383.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$890.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$685.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$657.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$726.10
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cash Price |
$411.00
|
| Rate for Payer: Cigna Commercial |
$1,260.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$1,219.30
|
| Rate for Payer: HFN Commercial |
$1,260.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,027.50
|
| Rate for Payer: Multiplan Commercial |
$1,096.00
|
| Rate for Payer: NAPHCARE Commercial |
$822.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,260.40
|
| Rate for Payer: Quartz Beloit One Network |
$671.30
|
| Rate for Payer: Quartz Commercial |
$890.50
|
| Rate for Payer: Quartz Medicare Advantage |
$822.00
|
| Rate for Payer: The Alliance Commercial |
$5,480.00
|
| Rate for Payer: WEA Trust Commercial |
$753.50
|
| Rate for Payer: WPS Commercial |
$1,014.76
|
|
|
Dialysis Circuit Central Stent
|
Facility
|
OP
|
$6,182.00
|
|
|
Service Code
|
CPT 36908
|
| Hospital Charge Code |
5218696
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,730.96 |
| Max. Negotiated Rate |
$24,728.00 |
| Rate for Payer: Aetna Commercial |
$5,563.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,316.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,730.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,018.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,091.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,967.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,276.46
|
| Rate for Payer: Cash Price |
$1,854.60
|
| Rate for Payer: Cash Price |
$1,854.60
|
| Rate for Payer: Cigna Commercial |
$5,687.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$5,501.98
|
| Rate for Payer: HFN Commercial |
$5,687.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,636.50
|
| Rate for Payer: Multiplan Commercial |
$4,945.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,709.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,687.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,029.18
|
| Rate for Payer: Quartz Commercial |
$4,018.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.20
|
| Rate for Payer: The Alliance Commercial |
$24,728.00
|
| Rate for Payer: WEA Trust Commercial |
$3,400.10
|
| Rate for Payer: WPS Commercial |
$4,579.01
|
|
|
Dialysis Circuit Central Stent
|
Facility
|
IP
|
$6,182.00
|
|
|
Service Code
|
CPT 36908
|
| Hospital Charge Code |
5218696
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,029.18 |
| Max. Negotiated Rate |
$5,687.44 |
| Rate for Payer: Aetna Commercial |
$5,563.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,316.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,276.46
|
| Rate for Payer: Cash Price |
$1,854.60
|
| Rate for Payer: Cigna Commercial |
$5,687.44
|
| Rate for Payer: Health EOS Commercial |
$5,501.98
|
| Rate for Payer: HFN Commercial |
$5,687.44
|
| Rate for Payer: Multiplan Commercial |
$4,945.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,709.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,687.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,029.18
|
| Rate for Payer: Quartz Commercial |
$3,709.20
|
| Rate for Payer: WEA Trust Commercial |
$3,400.10
|
| Rate for Payer: WPS Commercial |
$4,579.01
|
|
|
Dialysis Circuit Embolization
|
Facility
|
OP
|
$4,600.00
|
|
|
Service Code
|
CPT 36909
|
| Hospital Charge Code |
5218697
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,288.00 |
| Max. Negotiated Rate |
$18,400.00 |
| Rate for Payer: Aetna Commercial |
$4,140.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,956.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,288.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,990.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,300.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,208.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,438.00
|
| Rate for Payer: Cash Price |
$1,380.00
|
| Rate for Payer: Cash Price |
$1,380.00
|
| Rate for Payer: Cigna Commercial |
$4,232.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Health EOS Commercial |
$4,094.00
|
| Rate for Payer: HFN Commercial |
$4,232.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,450.00
|
| Rate for Payer: Multiplan Commercial |
$3,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,760.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,232.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,254.00
|
| Rate for Payer: Quartz Commercial |
$2,990.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,760.00
|
| Rate for Payer: The Alliance Commercial |
$18,400.00
|
| Rate for Payer: WEA Trust Commercial |
$2,530.00
|
| Rate for Payer: WPS Commercial |
$3,407.22
|
|
|
Dialysis Circuit Embolization
|
Facility
|
IP
|
$4,600.00
|
|
|
Service Code
|
CPT 36909
|
| Hospital Charge Code |
5218697
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,254.00 |
| Max. Negotiated Rate |
$4,232.00 |
| Rate for Payer: Aetna Commercial |
$4,140.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,956.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,438.00
|
| Rate for Payer: Cash Price |
$1,380.00
|
| Rate for Payer: Cigna Commercial |
$4,232.00
|
| Rate for Payer: Health EOS Commercial |
$4,094.00
|
| Rate for Payer: HFN Commercial |
$4,232.00
|
| Rate for Payer: Multiplan Commercial |
$3,680.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,760.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,232.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,254.00
|
| Rate for Payer: Quartz Commercial |
$2,760.00
|
| Rate for Payer: WEA Trust Commercial |
$2,530.00
|
| Rate for Payer: WPS Commercial |
$3,407.22
|
|
|
Dialysis Circuit Mech Thrombectomy
|
Facility
|
IP
|
$4,568.00
|
|
|
Service Code
|
CPT 36904
|
| Hospital Charge Code |
5218692
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,238.32 |
| Max. Negotiated Rate |
$4,202.56 |
| Rate for Payer: Aetna Commercial |
$4,111.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,928.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,421.04
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$4,202.56
|
| Rate for Payer: Health EOS Commercial |
$4,065.52
|
| Rate for Payer: HFN Commercial |
$4,202.56
|
| Rate for Payer: Multiplan Commercial |
$3,654.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,740.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,202.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,238.32
|
| Rate for Payer: Quartz Commercial |
$2,740.80
|
| Rate for Payer: WEA Trust Commercial |
$2,512.40
|
| Rate for Payer: WPS Commercial |
$3,383.52
|
|
|
Dialysis Circuit Mech Thrombectomy
|
Facility
|
OP
|
$4,568.00
|
|
|
Service Code
|
CPT 36904
|
| Hospital Charge Code |
5218692
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,238.32 |
| Max. Negotiated Rate |
$22,597.64 |
| Rate for Payer: Aetna Commercial |
$4,111.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,928.48
|
| Rate for Payer: Aetna Managed Medicare |
$5,649.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,318.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,785.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,096.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,649.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,421.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,649.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,649.41
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Cigna Commercial |
$4,202.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,649.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,649.41
|
| Rate for Payer: Health EOS Commercial |
$4,065.52
|
| Rate for Payer: HFN Commercial |
$4,202.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,015.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,649.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,649.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,649.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,649.41
|
| Rate for Payer: Multiplan Commercial |
$3,654.40
|
| Rate for Payer: NAPHCARE Commercial |
$8,474.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,202.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,238.32
|
| Rate for Payer: Quartz Commercial |
$2,969.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,649.41
|
| Rate for Payer: The Alliance Commercial |
$22,597.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,649.41
|
| Rate for Payer: United Healthcare PPO |
$6,154.00
|
| Rate for Payer: WEA Trust Commercial |
$2,512.40
|
| Rate for Payer: Wellcare Medicare |
$5,649.41
|
| Rate for Payer: WPS Commercial |
$3,383.52
|
|
