|
Delatestryl 100 mg Charge
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.48
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$11.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$11.23
|
| Rate for Payer: The Alliance Commercial |
$9.36
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Delatestryl 100 mg Charge
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Delatestryl 100 mg Charge
|
Professional
|
Both
|
$18.00
|
|
| Hospital Charge Code |
2958976
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$17.78 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.23
|
| Rate for Payer: Health EOS Commercial |
$17.04
|
| Rate for Payer: HFN Commercial |
$17.78
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.78
|
| Rate for Payer: Quartz Beloit One Network |
$8.24
|
| Rate for Payer: Quartz Commercial |
$10.67
|
| Rate for Payer: The Alliance Commercial |
$9.36
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
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 |
$303.76 |
| Max. Negotiated Rate |
$3,450.10 |
| Rate for Payer: Aetna Commercial |
$3,450.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,123.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.76
|
| Rate for Payer: Anthem Medicare Advantage |
$303.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$303.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$303.76
|
| Rate for Payer: Cash Price |
$1,047.60
|
| Rate for Payer: Cash Price |
$1,047.60
|
| Rate for Payer: Cash Price |
$1,047.60
|
| Rate for Payer: Cigna Commercial |
$3,450.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.76
|
| Rate for Payer: Health EOS Commercial |
$3,304.83
|
| Rate for Payer: HFN Commercial |
$3,450.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,185.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,185.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$303.76
|
| Rate for Payer: Multiplan Commercial |
$2,905.34
|
| Rate for Payer: NAPHCARE Commercial |
$455.64
|
| Rate for Payer: Preferred Network Access Commercial |
$3,450.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,597.94
|
| Rate for Payer: Quartz Commercial |
$2,070.06
|
| Rate for Payer: Quartz Medicare Advantage |
$303.76
|
| Rate for Payer: The Alliance Commercial |
$1,290.99
|
| Rate for Payer: United Healthcare Medicaid |
$325.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$303.76
|
| Rate for Payer: WEA Trust Commercial |
$1,997.42
|
| Rate for Payer: WPS Commercial |
$1,366.93
|
|
|
DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS, OR LIPS
|
Facility
|
OP
|
$8,685.50
|
|
|
Service Code
|
CPT 15630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,171.37 |
| Max. Negotiated Rate |
$8,685.50 |
| Rate for Payer: Aetna Managed Medicare |
$2,171.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,171.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,171.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,171.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,077.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,171.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,171.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,171.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,171.37
|
| Rate for Payer: NAPHCARE Commercial |
$3,257.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,171.37
|
| Rate for Payer: The Alliance Commercial |
$8,685.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,171.37
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,171.37
|
|
|
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 |
$2,524.56 |
| Max. Negotiated Rate |
$4,739.99 |
| Rate for Payer: Aetna Commercial |
$4,636.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,430.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,730.64
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,739.99
|
| Rate for Payer: Health EOS Commercial |
$4,585.42
|
| Rate for Payer: HFN Commercial |
$4,739.99
|
| Rate for Payer: Multiplan Commercial |
$4,121.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4,739.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.56
|
| Rate for Payer: Quartz Commercial |
$3,091.30
|
| Rate for Payer: WEA Trust Commercial |
$2,833.69
|
| Rate for Payer: WPS Commercial |
$3,816.07
|
|
|
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 |
$1,442.60 |
| Max. Negotiated Rate |
$4,739.99 |
| Rate for Payer: Aetna Commercial |
$4,636.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,430.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,442.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,348.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,576.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,473.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,730.64
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,739.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,883.23
|
| Rate for Payer: Health EOS Commercial |
$4,585.42
|
| Rate for Payer: HFN Commercial |
$4,739.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,864.12
|
| Rate for Payer: Multiplan Commercial |
$4,121.73
|
| Rate for Payer: NAPHCARE Commercial |
$3,091.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,739.99
|
| Rate for Payer: Quartz Beloit One Network |
$2,524.56
|
| Rate for Payer: Quartz Commercial |
$3,348.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,091.30
|
| Rate for Payer: The Alliance Commercial |
$2,576.08
|
| Rate for Payer: WEA Trust Commercial |
$2,833.69
|
| Rate for Payer: WPS Commercial |
$3,816.07
|
|
|
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 |
$1,042.64 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,276.70
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
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 |
$595.80 |
| Max. Negotiated Rate |
$1,957.61 |
| Rate for Payer: Aetna Commercial |
$1,915.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,829.94
|
| Rate for Payer: Aetna Managed Medicare |
$595.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,383.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,063.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,021.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,127.76
|
| Rate for Payer: Cash Price |
$613.80
|
| Rate for Payer: Cigna Commercial |
$1,957.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,190.77
|
| Rate for Payer: Health EOS Commercial |
$1,893.78
|
| Rate for Payer: HFN Commercial |
$1,957.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,595.88
|
| Rate for Payer: Multiplan Commercial |
$1,702.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,276.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,957.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,042.64
|
| Rate for Payer: Quartz Commercial |
$1,383.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,276.70
|
| Rate for Payer: The Alliance Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$1,170.31
|
| Rate for Payer: WPS Commercial |
$1,576.03
|
|
|
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 |
$578.32 |
| Max. Negotiated Rate |
$1,900.20 |
| Rate for Payer: Aetna Commercial |
$1,858.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,776.28
|
| Rate for Payer: Aetna Managed Medicare |
$578.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,342.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,032.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$991.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,094.68
|
| Rate for Payer: Cash Price |
$595.80
|
| Rate for Payer: Cigna Commercial |
$1,900.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,155.85
|
| Rate for Payer: Health EOS Commercial |
$1,838.24
|
| Rate for Payer: HFN Commercial |
$1,900.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,549.08
|
| Rate for Payer: Multiplan Commercial |
$1,652.35
|
| Rate for Payer: NAPHCARE Commercial |
$1,239.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,900.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,012.07
|
| Rate for Payer: Quartz Commercial |
$1,342.54
|
| Rate for Payer: Quartz Medicare Advantage |
$1,239.26
|
| Rate for Payer: The Alliance Commercial |
$1,032.72
|
| Rate for Payer: WEA Trust Commercial |
$1,135.99
|
| Rate for Payer: WPS Commercial |
$1,529.82
|
|
|
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 |
$1,012.07 |
| Max. Negotiated Rate |
$1,900.20 |
| Rate for Payer: Aetna Commercial |
$1,858.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,776.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,094.68
|
| Rate for Payer: Cash Price |
$595.80
|
| Rate for Payer: Cigna Commercial |
$1,900.20
|
| Rate for Payer: Health EOS Commercial |
$1,838.24
|
| Rate for Payer: HFN Commercial |
$1,900.20
|
| Rate for Payer: Multiplan Commercial |
$1,652.35
|
| Rate for Payer: Preferred Network Access Commercial |
$1,900.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,012.07
|
| Rate for Payer: Quartz Commercial |
$1,239.26
|
| Rate for Payer: WEA Trust Commercial |
$1,135.99
|
| Rate for Payer: WPS Commercial |
$1,529.82
|
|
|
DELIVERY NEEDLE NORIAN 10GA X 10CM DLS-7103-01S
|
Facility
|
IP
|
$806.00
|
|
| Hospital Charge Code |
3842758
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$410.74 |
| Max. Negotiated Rate |
$771.18 |
| Rate for Payer: Aetna Commercial |
$754.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$720.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.27
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$771.18
|
| Rate for Payer: Health EOS Commercial |
$746.03
|
| Rate for Payer: HFN Commercial |
$771.18
|
| Rate for Payer: Multiplan Commercial |
$670.59
|
| Rate for Payer: Preferred Network Access Commercial |
$771.18
|
| Rate for Payer: Quartz Beloit One Network |
$410.74
|
| Rate for Payer: Quartz Commercial |
$502.94
|
| Rate for Payer: WEA Trust Commercial |
$461.03
|
| Rate for Payer: WPS Commercial |
$620.86
|
|
|
DELIVERY NEEDLE NORIAN 10GA X 10CM DLS-7103-01S
|
Facility
|
OP
|
$806.00
|
|
| Hospital Charge Code |
3842758
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$771.18 |
| Rate for Payer: Aetna Commercial |
$754.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$720.89
|
| Rate for Payer: Aetna Managed Medicare |
$234.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$544.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$419.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$402.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$444.27
|
| Rate for Payer: Cash Price |
$241.80
|
| Rate for Payer: Cigna Commercial |
$771.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$469.09
|
| Rate for Payer: Health EOS Commercial |
$746.03
|
| Rate for Payer: HFN Commercial |
$771.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.68
|
| Rate for Payer: Multiplan Commercial |
$670.59
|
| Rate for Payer: NAPHCARE Commercial |
$502.94
|
| Rate for Payer: Preferred Network Access Commercial |
$771.18
|
| Rate for Payer: Quartz Beloit One Network |
$410.74
|
| Rate for Payer: Quartz Commercial |
$544.86
|
| Rate for Payer: Quartz Medicare Advantage |
$502.94
|
| Rate for Payer: The Alliance Commercial |
$419.12
|
| Rate for Payer: WEA Trust Commercial |
$461.03
|
| Rate for Payer: WPS Commercial |
$620.86
|
|
|
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 |
$17.11 |
| Max. Negotiated Rate |
$75.28 |
| Rate for Payer: Aetna Commercial |
$61.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.68
|
| Rate for Payer: Aetna Managed Medicare |
$17.11
|
| Rate for Payer: Anthem Medicare Advantage |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.11
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$61.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.11
|
| Rate for Payer: Health EOS Commercial |
$58.91
|
| Rate for Payer: HFN Commercial |
$61.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.11
|
| Rate for Payer: Multiplan Commercial |
$51.79
|
| Rate for Payer: NAPHCARE Commercial |
$25.66
|
| Rate for Payer: Preferred Network Access Commercial |
$61.50
|
| Rate for Payer: Quartz Beloit One Network |
$28.49
|
| Rate for Payer: Quartz Commercial |
$36.90
|
| Rate for Payer: Quartz Medicare Advantage |
$17.11
|
| Rate for Payer: The Alliance Commercial |
$67.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.11
|
| Rate for Payer: WEA Trust Commercial |
$35.61
|
| Rate for Payer: WPS Commercial |
$75.28
|
|
|
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 |
$31.72 |
| Max. Negotiated Rate |
$59.56 |
| Rate for Payer: Aetna Commercial |
$58.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.31
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$59.56
|
| Rate for Payer: Health EOS Commercial |
$57.62
|
| Rate for Payer: HFN Commercial |
$59.56
|
| Rate for Payer: Multiplan Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$59.56
|
| Rate for Payer: Quartz Beloit One Network |
$31.72
|
| Rate for Payer: Quartz Commercial |
$38.84
|
| Rate for Payer: WEA Trust Commercial |
$35.61
|
| Rate for Payer: WPS Commercial |
$47.95
|
|
|
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 |
$17.11 |
| Max. Negotiated Rate |
$68.43 |
| Rate for Payer: Aetna Commercial |
$58.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.68
|
| Rate for Payer: Aetna Managed Medicare |
$17.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.40
|
| Rate for Payer: Anthem Medicare Advantage |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.11
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$59.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.11
|
| Rate for Payer: Health EOS Commercial |
$57.62
|
| Rate for Payer: HFN Commercial |
$59.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.11
|
| Rate for Payer: Multiplan Commercial |
$51.79
|
| Rate for Payer: NAPHCARE Commercial |
$25.66
|
| Rate for Payer: Preferred Network Access Commercial |
$59.56
|
| Rate for Payer: Quartz Beloit One Network |
$31.72
|
| Rate for Payer: Quartz Commercial |
$42.08
|
| Rate for Payer: Quartz Medicare Advantage |
$17.11
|
| Rate for Payer: The Alliance Commercial |
$68.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.11
|
| Rate for Payer: United Healthcare PPO |
$48.55
|
| Rate for Payer: WEA Trust Commercial |
$35.61
|
| Rate for Payer: Wellcare Medicare |
$17.11
|
| Rate for Payer: WPS Commercial |
$47.95
|
|
|
Delta Aminolevulinic Acid, Urine
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$193.65 |
| Rate for Payer: Aetna Commercial |
$193.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$17.11
|
| Rate for Payer: Anthem Medicare Advantage |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.11
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$193.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.11
|
| Rate for Payer: Health EOS Commercial |
$185.49
|
| Rate for Payer: HFN Commercial |
$193.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.11
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$25.66
|
| Rate for Payer: Preferred Network Access Commercial |
$193.65
|
| Rate for Payer: Quartz Beloit One Network |
$89.69
|
| Rate for Payer: Quartz Commercial |
$116.19
|
| Rate for Payer: Quartz Medicare Advantage |
$17.11
|
| Rate for Payer: The Alliance Commercial |
$67.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.11
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$75.28
|
|
|
Delta Aminolevulinic Acid, Urine
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Delta Aminolevulinic Acid, Urine
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 82135
|
| Hospital Charge Code |
4526698
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$17.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.40
|
| Rate for Payer: Anthem Medicare Advantage |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.11
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.11
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.11
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$25.66
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$17.11
|
| Rate for Payer: The Alliance Commercial |
$68.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.11
|
| Rate for Payer: United Healthcare PPO |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: Wellcare Medicare |
$17.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
DELUXE SQUARE REBOUNDER
|
Facility
|
OP
|
$5,445.00
|
|
| Hospital Charge Code |
2973658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,585.58 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,585.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,680.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,831.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,718.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,168.99
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,247.10
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.68
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,680.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,397.68
|
| Rate for Payer: The Alliance Commercial |
$2,831.40
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
DELUXE SQUARE REBOUNDER
|
Facility
|
IP
|
$5,445.00
|
|
| Hospital Charge Code |
2973658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,774.77 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,397.68
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
Demerol 100 mg Charge
|
Professional
|
Both
|
$6.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2958935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$5.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$8.48
|
| Rate for Payer: Anthem Medicare Advantage |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.48
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.18
|
| Rate for Payer: Health EOS Commercial |
$5.68
|
| Rate for Payer: HFN Commercial |
$5.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.48
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$12.71
|
| Rate for Payer: Preferred Network Access Commercial |
$5.93
|
| Rate for Payer: Quartz Beloit One Network |
$2.75
|
| Rate for Payer: Quartz Commercial |
$3.56
|
| Rate for Payer: Quartz Medicare Advantage |
$8.48
|
| Rate for Payer: The Alliance Commercial |
$23.31
|
| Rate for Payer: United Healthcare Medicaid |
$8.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.48
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$17.94
|
|
|
Demerol 100 mg Charge
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2958935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$33.90 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$33.90
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$17.94
|
|
|
Demerol 100 mg Charge
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2958935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Demonstrates
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2990173
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$27.56
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
