|
DUPUYTREN'S CONTRACTURE RELEASE
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
DUPUYTREN'S CONTRACTURE RELEASE
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2959999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
Durysta 10 mcg J7351
|
Professional
|
Both
|
$4,715.00
|
|
|
Service Code
|
HCPCS J7351
|
| Hospital Charge Code |
5965658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.19 |
| Max. Negotiated Rate |
$4,479.25 |
| Rate for Payer: Aetna Commercial |
$4,479.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,054.90
|
| Rate for Payer: Cash Price |
$1,414.50
|
| Rate for Payer: Cash Price |
$1,414.50
|
| Rate for Payer: Cigna Commercial |
$4,479.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.19
|
| Rate for Payer: Health EOS Commercial |
$4,290.65
|
| Rate for Payer: HFN Commercial |
$4,479.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$301.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$301.56
|
| Rate for Payer: Multiplan Commercial |
$3,772.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,479.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,074.60
|
| Rate for Payer: Quartz Commercial |
$2,687.55
|
| Rate for Payer: The Alliance Commercial |
$2,357.50
|
| Rate for Payer: United Healthcare Medicaid |
$206.19
|
| Rate for Payer: WEA Trust Commercial |
$2,593.25
|
| Rate for Payer: WPS Commercial |
$515.48
|
|
|
Durysta 10 mcg J7351
|
Facility
|
OP
|
$4,715.00
|
|
|
Service Code
|
HCPCS J7351
|
| Hospital Charge Code |
5965658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.20 |
| Max. Negotiated Rate |
$4,337.80 |
| Rate for Payer: Aetna Commercial |
$4,243.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,054.90
|
| Rate for Payer: Aetna Managed Medicare |
$206.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,064.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,357.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,263.20
|
| Rate for Payer: Anthem Medicare Advantage |
$206.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,498.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$206.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$206.20
|
| Rate for Payer: Cash Price |
$1,414.50
|
| Rate for Payer: Cash Price |
$1,414.50
|
| Rate for Payer: Cigna Commercial |
$4,337.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$206.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$272.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$206.20
|
| Rate for Payer: Health EOS Commercial |
$4,196.35
|
| Rate for Payer: HFN Commercial |
$4,337.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$767.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$206.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$206.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$206.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$206.20
|
| Rate for Payer: Multiplan Commercial |
$3,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$309.31
|
| Rate for Payer: Preferred Network Access Commercial |
$4,337.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,310.35
|
| Rate for Payer: Quartz Commercial |
$3,064.75
|
| Rate for Payer: Quartz Medicare Advantage |
$206.20
|
| Rate for Payer: The Alliance Commercial |
$824.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$206.20
|
| Rate for Payer: WEA Trust Commercial |
$2,593.25
|
| Rate for Payer: Wellcare Medicare |
$206.20
|
| Rate for Payer: WPS Commercial |
$515.48
|
|
|
Durysta 10 mcg J7351
|
Facility
|
IP
|
$4,715.00
|
|
|
Service Code
|
HCPCS J7351
|
| Hospital Charge Code |
5965658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,310.35 |
| Max. Negotiated Rate |
$4,337.80 |
| Rate for Payer: Aetna Commercial |
$4,243.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,054.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,498.95
|
| Rate for Payer: Cash Price |
$1,414.50
|
| Rate for Payer: Cigna Commercial |
$4,337.80
|
| Rate for Payer: Health EOS Commercial |
$4,196.35
|
| Rate for Payer: HFN Commercial |
$4,337.80
|
| Rate for Payer: Multiplan Commercial |
$3,772.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,829.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,337.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,310.35
|
| Rate for Payer: Quartz Commercial |
$2,829.00
|
| Rate for Payer: WEA Trust Commercial |
$2,593.25
|
| Rate for Payer: WPS Commercial |
$3,492.40
|
|
|
DVT-bilateral 93970
|
Professional
|
Both
|
$428.00
|
|
|
Service Code
|
CPT 93970
|
| Hospital Charge Code |
3015440
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$169.05 |
| Max. Negotiated Rate |
$665.44 |
| Rate for Payer: Aetna Commercial |
$406.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$368.08
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cigna Commercial |
$406.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$169.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.80
|
| Rate for Payer: Health EOS Commercial |
$389.48
|
| Rate for Payer: HFN Commercial |
$406.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.44
|
| Rate for Payer: Multiplan Commercial |
$342.40
|
| Rate for Payer: Preferred Network Access Commercial |
$406.60
|
| Rate for Payer: Quartz Beloit One Network |
$188.32
|
| Rate for Payer: Quartz Commercial |
$243.96
|
| Rate for Payer: The Alliance Commercial |
$214.00
|
| Rate for Payer: United Healthcare Medicaid |
$169.05
|
| Rate for Payer: WEA Trust Commercial |
$235.40
|
| Rate for Payer: WPS Commercial |
$317.02
|
|
|
DVT UNILATERAL 93971
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
CPT 93971
|
| Hospital Charge Code |
3015445
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.68 |
| Max. Negotiated Rate |
$418.09 |
| Rate for Payer: Aetna Commercial |
$310.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$310.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.20
|
| Rate for Payer: Health EOS Commercial |
$297.57
|
| Rate for Payer: HFN Commercial |
$310.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$418.09
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: Preferred Network Access Commercial |
$310.65
|
| Rate for Payer: Quartz Beloit One Network |
$143.88
|
| Rate for Payer: Quartz Commercial |
$186.39
|
| Rate for Payer: The Alliance Commercial |
$163.50
|
| Rate for Payer: United Healthcare Medicaid |
$108.68
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
DVT UNILATERAL 9397126
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
CPT 93971 26
|
| Hospital Charge Code |
3015447
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.14 |
| Max. Negotiated Rate |
$310.65 |
| Rate for Payer: Aetna Commercial |
$310.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$310.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.20
|
| Rate for Payer: Health EOS Commercial |
$297.57
|
| Rate for Payer: HFN Commercial |
$310.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.14
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: Preferred Network Access Commercial |
$310.65
|
| Rate for Payer: Quartz Beloit One Network |
$143.88
|
| Rate for Payer: Quartz Commercial |
$186.39
|
| Rate for Payer: The Alliance Commercial |
$163.50
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
DXA Bone Denisity, Axial 77080
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
3243523
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$128.63 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.63
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
DXA Bone Density, Axial 7708026
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
CPT 77080 26
|
| Hospital Charge Code |
3242174
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.11 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Aetna Commercial |
$92.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.42
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$88.27
|
| Rate for Payer: HFN Commercial |
$92.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.11
|
| Rate for Payer: Multiplan Commercial |
$77.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.15
|
| Rate for Payer: Quartz Beloit One Network |
$42.68
|
| Rate for Payer: Quartz Commercial |
$55.29
|
| Rate for Payer: The Alliance Commercial |
$48.50
|
| Rate for Payer: WEA Trust Commercial |
$53.35
|
| Rate for Payer: WPS Commercial |
$71.85
|
|
|
DXA Bone Density/Peripheral 7708126
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
CPT 77081 26
|
| Hospital Charge Code |
3358866
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.28 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$154.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$154.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.80
|
| Rate for Payer: Health EOS Commercial |
$148.33
|
| Rate for Payer: HFN Commercial |
$154.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.28
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: Preferred Network Access Commercial |
$154.85
|
| Rate for Payer: Quartz Beloit One Network |
$71.72
|
| Rate for Payer: Quartz Commercial |
$92.91
|
| Rate for Payer: The Alliance Commercial |
$81.50
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
DX BRONCHOSCOPE/BRUSH 31623
|
Professional
|
Both
|
$1,805.00
|
|
|
Service Code
|
CPT 31623
|
| Hospital Charge Code |
5619672
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$206.73 |
| Max. Negotiated Rate |
$1,714.75 |
| Rate for Payer: Aetna Commercial |
$1,714.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,552.30
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cash Price |
$541.50
|
| Rate for Payer: Cigna Commercial |
$1,714.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,083.00
|
| Rate for Payer: Health EOS Commercial |
$1,642.55
|
| Rate for Payer: HFN Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.80
|
| Rate for Payer: Multiplan Commercial |
$1,444.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,714.75
|
| Rate for Payer: Quartz Beloit One Network |
$794.20
|
| Rate for Payer: Quartz Commercial |
$1,028.85
|
| Rate for Payer: The Alliance Commercial |
$902.50
|
| Rate for Payer: United Healthcare Medicaid |
$206.73
|
| Rate for Payer: WEA Trust Commercial |
$992.75
|
| Rate for Payer: WPS Commercial |
$1,336.96
|
|
|
DX BRONCHOSCOPE/LAVAGE 31624
|
Professional
|
Both
|
$1,877.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
3014399
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$208.62 |
| Max. Negotiated Rate |
$1,783.15 |
| Rate for Payer: Aetna Commercial |
$1,783.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,614.22
|
| Rate for Payer: Cash Price |
$563.10
|
| Rate for Payer: Cash Price |
$563.10
|
| Rate for Payer: Cigna Commercial |
$1,783.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,126.20
|
| Rate for Payer: Health EOS Commercial |
$1,708.07
|
| Rate for Payer: HFN Commercial |
$1,783.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$452.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$452.65
|
| Rate for Payer: Multiplan Commercial |
$1,501.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,783.15
|
| Rate for Payer: Quartz Beloit One Network |
$825.88
|
| Rate for Payer: Quartz Commercial |
$1,069.89
|
| Rate for Payer: The Alliance Commercial |
$938.50
|
| Rate for Payer: United Healthcare Medicaid |
$208.62
|
| Rate for Payer: WEA Trust Commercial |
$1,032.35
|
| Rate for Payer: WPS Commercial |
$1,390.29
|
|
|
DX BRONCHOSCOPE/WASH 31622
|
Professional
|
Both
|
$1,632.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
3014398
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$277.31 |
| Max. Negotiated Rate |
$1,550.40 |
| Rate for Payer: Aetna Commercial |
$1,550.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,403.52
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,550.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$277.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.20
|
| Rate for Payer: Health EOS Commercial |
$1,485.12
|
| Rate for Payer: HFN Commercial |
$1,550.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$440.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$440.97
|
| Rate for Payer: Multiplan Commercial |
$1,305.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,550.40
|
| Rate for Payer: Quartz Beloit One Network |
$718.08
|
| Rate for Payer: Quartz Commercial |
$930.24
|
| Rate for Payer: The Alliance Commercial |
$816.00
|
| Rate for Payer: United Healthcare Medicaid |
$277.31
|
| Rate for Payer: WEA Trust Commercial |
$897.60
|
| Rate for Payer: WPS Commercial |
$1,208.82
|
|
|
DX LARYNGOSCOPY EXCL NB 31525
|
Professional
|
Both
|
$1,145.00
|
|
|
Service Code
|
CPT 31525
|
| Hospital Charge Code |
3014386
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$198.18 |
| Max. Negotiated Rate |
$1,087.75 |
| Rate for Payer: Aetna Commercial |
$1,087.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$984.70
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,087.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$687.00
|
| Rate for Payer: Health EOS Commercial |
$1,041.95
|
| Rate for Payer: HFN Commercial |
$1,087.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$524.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$524.24
|
| Rate for Payer: Multiplan Commercial |
$916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.75
|
| Rate for Payer: Quartz Beloit One Network |
$503.80
|
| Rate for Payer: Quartz Commercial |
$652.65
|
| Rate for Payer: The Alliance Commercial |
$572.50
|
| Rate for Payer: United Healthcare Medicaid |
$198.18
|
| Rate for Payer: WEA Trust Commercial |
$629.75
|
| Rate for Payer: WPS Commercial |
$848.10
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
|
IP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,463.81 |
| Max. Negotiated Rate |
$6,503.48 |
| Rate for Payer: Aetna Commercial |
$6,362.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,079.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,746.57
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,503.48
|
| Rate for Payer: Health EOS Commercial |
$6,291.41
|
| Rate for Payer: HFN Commercial |
$6,503.48
|
| Rate for Payer: Multiplan Commercial |
$5,655.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,241.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,503.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,463.81
|
| Rate for Payer: Quartz Commercial |
$4,241.40
|
| Rate for Payer: WEA Trust Commercial |
$3,887.95
|
| Rate for Payer: WPS Commercial |
$5,236.01
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
|
OP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,979.32 |
| Max. Negotiated Rate |
$28,276.00 |
| Rate for Payer: Aetna Commercial |
$6,362.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,079.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,979.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,594.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,534.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,393.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,746.57
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,503.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,955.81
|
| Rate for Payer: Health EOS Commercial |
$6,291.41
|
| Rate for Payer: HFN Commercial |
$6,503.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,301.75
|
| Rate for Payer: Multiplan Commercial |
$5,655.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,241.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,503.48
|
| Rate for Payer: Quartz Beloit One Network |
$3,463.81
|
| Rate for Payer: Quartz Commercial |
$4,594.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,241.40
|
| Rate for Payer: The Alliance Commercial |
$28,276.00
|
| Rate for Payer: WEA Trust Commercial |
$3,887.95
|
| Rate for Payer: WPS Commercial |
$5,236.01
|
|
|
Dynamic Pro/Sup Splint
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$294.98 |
| Max. Negotiated Rate |
$553.84 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$361.20
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
Dynamic Pro/Sup Splint
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$2,408.00 |
| Rate for Payer: Aetna Commercial |
$541.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.72
|
| Rate for Payer: Aetna Managed Medicare |
$168.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$289.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$289.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$289.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.06
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$553.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.88
|
| Rate for Payer: Health EOS Commercial |
$535.78
|
| Rate for Payer: HFN Commercial |
$553.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.50
|
| Rate for Payer: Multiplan Commercial |
$481.60
|
| Rate for Payer: NAPHCARE Commercial |
$361.20
|
| Rate for Payer: Preferred Network Access Commercial |
$553.84
|
| Rate for Payer: Quartz Beloit One Network |
$294.98
|
| Rate for Payer: Quartz Commercial |
$391.30
|
| Rate for Payer: Quartz Medicare Advantage |
$361.20
|
| Rate for Payer: The Alliance Commercial |
$2,408.00
|
| Rate for Payer: WEA Trust Commercial |
$331.10
|
| Rate for Payer: WPS Commercial |
$445.90
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,023.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.40 |
| Max. Negotiated Rate |
$6,820.00 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Aetna Managed Medicare |
$477.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$852.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.12
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,278.75
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,108.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.00
|
| Rate for Payer: The Alliance Commercial |
$6,820.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$20,119.00
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$7,237.06 |
| Max. Negotiated Rate |
$20,119.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,237.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,525.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,899.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,305.72
|
| Rate for Payer: Anthem Medicare Advantage |
$7,237.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,237.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,237.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,237.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,550.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,237.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,521.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,237.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,237.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,237.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,237.06
|
| Rate for Payer: NAPHCARE Commercial |
$10,855.59
|
| Rate for Payer: Quartz Medicare Advantage |
$7,237.06
|
| Rate for Payer: The Alliance Commercial |
$20,119.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,237.06
|
| Rate for Payer: United Healthcare PPO |
$11,305.29
|
| Rate for Payer: Wellcare Medicare |
$7,237.06
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$17.87 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: HFN Commercial |
$51.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
