|
Epinephrine 1:1000 30ml vial [Med]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2974933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Epinephrine 1:1000 30ml vial [Med]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2974933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.07
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$2.03
|
|
|
EP Intra-Artial/Vent Mapping Tachy +
|
Facility
|
IP
|
$866.00
|
|
|
Service Code
|
CPT 93609
|
| Hospital Charge Code |
3052505
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$424.34 |
| Max. Negotiated Rate |
$796.72 |
| Rate for Payer: Aetna Commercial |
$779.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$744.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$458.98
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cigna Commercial |
$796.72
|
| Rate for Payer: Health EOS Commercial |
$770.74
|
| Rate for Payer: HFN Commercial |
$796.72
|
| Rate for Payer: Multiplan Commercial |
$692.80
|
| Rate for Payer: NAPHCARE Commercial |
$519.60
|
| Rate for Payer: Preferred Network Access Commercial |
$796.72
|
| Rate for Payer: Quartz Beloit One Network |
$424.34
|
| Rate for Payer: Quartz Commercial |
$519.60
|
| Rate for Payer: WEA Trust Commercial |
$476.30
|
| Rate for Payer: WPS Commercial |
$641.45
|
|
|
EP Intra-Artial/Vent Mapping Tachy +
|
Facility
|
OP
|
$866.00
|
|
|
Service Code
|
CPT 93609
|
| Hospital Charge Code |
3052505
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$242.48 |
| Max. Negotiated Rate |
$29,139.00 |
| Rate for Payer: Aetna Commercial |
$779.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$744.76
|
| Rate for Payer: Aetna Managed Medicare |
$242.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$458.98
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cash Price |
$259.80
|
| Rate for Payer: Cigna Commercial |
$796.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$484.61
|
| Rate for Payer: Health EOS Commercial |
$770.74
|
| Rate for Payer: HFN Commercial |
$796.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$649.50
|
| Rate for Payer: Multiplan Commercial |
$692.80
|
| Rate for Payer: NAPHCARE Commercial |
$519.60
|
| Rate for Payer: Preferred Network Access Commercial |
$796.72
|
| Rate for Payer: Quartz Beloit One Network |
$424.34
|
| Rate for Payer: Quartz Commercial |
$562.90
|
| Rate for Payer: Quartz Medicare Advantage |
$519.60
|
| Rate for Payer: The Alliance Commercial |
$3,464.00
|
| Rate for Payer: WEA Trust Commercial |
$476.30
|
| Rate for Payer: WPS Commercial |
$641.45
|
|
|
EP Intra-Atrial Pacing
|
Facility
|
OP
|
$1,258.00
|
|
|
Service Code
|
CPT 93610
|
| Hospital Charge Code |
4125699
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$616.42 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$1,132.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,081.88
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$666.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$377.40
|
| Rate for Payer: Cash Price |
$377.40
|
| Rate for Payer: Cash Price |
$377.40
|
| Rate for Payer: Cigna Commercial |
$1,157.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$703.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$1,119.62
|
| Rate for Payer: HFN Commercial |
$1,157.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$1,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,157.36
|
| Rate for Payer: Quartz Beloit One Network |
$616.42
|
| Rate for Payer: Quartz Commercial |
$817.70
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$691.90
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$931.80
|
|
|
EP Intra-Atrial Pacing
|
Facility
|
IP
|
$1,258.00
|
|
|
Service Code
|
CPT 93610
|
| Hospital Charge Code |
4125699
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$616.42 |
| Max. Negotiated Rate |
$1,157.36 |
| Rate for Payer: Aetna Commercial |
$1,132.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,081.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$666.74
|
| Rate for Payer: Cash Price |
$377.40
|
| Rate for Payer: Cigna Commercial |
$1,157.36
|
| Rate for Payer: Health EOS Commercial |
$1,119.62
|
| Rate for Payer: HFN Commercial |
$1,157.36
|
| Rate for Payer: Multiplan Commercial |
$1,006.40
|
| Rate for Payer: NAPHCARE Commercial |
$754.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,157.36
|
| Rate for Payer: Quartz Beloit One Network |
$616.42
|
| Rate for Payer: Quartz Commercial |
$754.80
|
| Rate for Payer: WEA Trust Commercial |
$691.90
|
| Rate for Payer: WPS Commercial |
$931.80
|
|
|
EP Intra-Atrial Recording
|
Facility
|
OP
|
$881.00
|
|
|
Service Code
|
CPT 93602
|
| Hospital Charge Code |
4125701
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$431.69 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$792.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.66
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$466.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$810.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$493.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$784.09
|
| Rate for Payer: HFN Commercial |
$810.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$704.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$810.52
|
| Rate for Payer: Quartz Beloit One Network |
$431.69
|
| Rate for Payer: Quartz Commercial |
$572.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$484.55
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$652.56
|
|
|
EP Intra-Atrial Recording
|
Facility
|
IP
|
$881.00
|
|
|
Service Code
|
CPT 93602
|
| Hospital Charge Code |
4125701
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$431.69 |
| Max. Negotiated Rate |
$810.52 |
| Rate for Payer: Aetna Commercial |
$792.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$757.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$466.93
|
| Rate for Payer: Cash Price |
$264.30
|
| Rate for Payer: Cigna Commercial |
$810.52
|
| Rate for Payer: Health EOS Commercial |
$784.09
|
| Rate for Payer: HFN Commercial |
$810.52
|
| Rate for Payer: Multiplan Commercial |
$704.80
|
| Rate for Payer: NAPHCARE Commercial |
$528.60
|
| Rate for Payer: Preferred Network Access Commercial |
$810.52
|
| Rate for Payer: Quartz Beloit One Network |
$431.69
|
| Rate for Payer: Quartz Commercial |
$528.60
|
| Rate for Payer: WEA Trust Commercial |
$484.55
|
| Rate for Payer: WPS Commercial |
$652.56
|
|
|
EP Intra Ventricular Pacing
|
Facility
|
OP
|
$1,117.00
|
|
|
Service Code
|
CPT 93612
|
| Hospital Charge Code |
4125698
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$547.33 |
| Max. Negotiated Rate |
$29,526.40 |
| Rate for Payer: Aetna Commercial |
$1,005.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$960.62
|
| Rate for Payer: Aetna Managed Medicare |
$7,381.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,381.60
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,027.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,381.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$625.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,381.60
|
| Rate for Payer: Health EOS Commercial |
$994.13
|
| Rate for Payer: HFN Commercial |
$1,027.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,459.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,381.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,381.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,381.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,381.60
|
| Rate for Payer: Multiplan Commercial |
$893.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,072.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,027.64
|
| Rate for Payer: Quartz Beloit One Network |
$547.33
|
| Rate for Payer: Quartz Commercial |
$726.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,381.60
|
| Rate for Payer: The Alliance Commercial |
$29,526.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,381.60
|
| Rate for Payer: WEA Trust Commercial |
$614.35
|
| Rate for Payer: Wellcare Medicare |
$7,381.60
|
| Rate for Payer: WPS Commercial |
$827.36
|
|
|
EP Intra Ventricular Pacing
|
Facility
|
IP
|
$1,117.00
|
|
|
Service Code
|
CPT 93612
|
| Hospital Charge Code |
4125698
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$547.33 |
| Max. Negotiated Rate |
$1,027.64 |
| Rate for Payer: Aetna Commercial |
$1,005.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$960.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$592.01
|
| Rate for Payer: Cash Price |
$335.10
|
| Rate for Payer: Cigna Commercial |
$1,027.64
|
| Rate for Payer: Health EOS Commercial |
$994.13
|
| Rate for Payer: HFN Commercial |
$1,027.64
|
| Rate for Payer: Multiplan Commercial |
$893.60
|
| Rate for Payer: NAPHCARE Commercial |
$670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,027.64
|
| Rate for Payer: Quartz Beloit One Network |
$547.33
|
| Rate for Payer: Quartz Commercial |
$670.20
|
| Rate for Payer: WEA Trust Commercial |
$614.35
|
| Rate for Payer: WPS Commercial |
$827.36
|
|
|
EPISIOTOMY OR VAGINAL REPAIR 59300
|
Professional
|
Both
|
$743.00
|
|
|
Service Code
|
CPT 59300
|
| Hospital Charge Code |
3015153
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$167.08 |
| Max. Negotiated Rate |
$705.85 |
| Rate for Payer: Aetna Commercial |
$705.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.98
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cash Price |
$222.90
|
| Rate for Payer: Cigna Commercial |
$705.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$167.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$445.80
|
| Rate for Payer: Health EOS Commercial |
$676.13
|
| Rate for Payer: HFN Commercial |
$705.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$464.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$464.80
|
| Rate for Payer: Multiplan Commercial |
$594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$705.85
|
| Rate for Payer: Quartz Beloit One Network |
$326.92
|
| Rate for Payer: Quartz Commercial |
$423.51
|
| Rate for Payer: The Alliance Commercial |
$371.50
|
| Rate for Payer: United Healthcare Medicaid |
$167.08
|
| Rate for Payer: WEA Trust Commercial |
$408.65
|
| Rate for Payer: WPS Commercial |
$550.34
|
|
|
EPISTAXIS CONTROL
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960016
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
EPISTAXIS CONTROL
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960016
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
EPISTAXIS WITH MCC
|
Facility
|
IP
|
$35,268.00
|
|
|
Service Code
|
MSDRG 150
|
| Min. Negotiated Rate |
$12,686.21 |
| Max. Negotiated Rate |
$35,268.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,686.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,483.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,066.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,014.18
|
| Rate for Payer: Anthem Medicare Advantage |
$12,686.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,686.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,686.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,686.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,217.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,686.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,632.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,686.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,686.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,686.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,686.21
|
| Rate for Payer: NAPHCARE Commercial |
$19,029.32
|
| Rate for Payer: Quartz Medicare Advantage |
$12,686.21
|
| Rate for Payer: The Alliance Commercial |
$35,268.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,686.21
|
| Rate for Payer: United Healthcare PPO |
$19,955.42
|
| Rate for Payer: Wellcare Medicare |
$12,686.21
|
|
|
EPISTAXIS WITHOUT MCC
|
Facility
|
IP
|
$20,810.00
|
|
|
Service Code
|
MSDRG 151
|
| Min. Negotiated Rate |
$7,485.69 |
| Max. Negotiated Rate |
$20,810.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,485.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,382.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,764.06
|
| Rate for Payer: Anthem Medicare Advantage |
$7,485.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,485.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,485.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,485.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,059.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,485.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,028.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,485.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,485.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,485.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,485.69
|
| Rate for Payer: NAPHCARE Commercial |
$11,228.54
|
| Rate for Payer: Quartz Medicare Advantage |
$7,485.69
|
| Rate for Payer: The Alliance Commercial |
$20,810.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,485.69
|
| Rate for Payer: United Healthcare PPO |
$11,700.00
|
| Rate for Payer: Wellcare Medicare |
$7,485.69
|
|
|
EP LV Pacing & Recording +
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
CPT 93622
|
| Hospital Charge Code |
3052509
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$563.99 |
| Max. Negotiated Rate |
$1,058.92 |
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$989.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$610.03
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cigna Commercial |
$1,058.92
|
| Rate for Payer: Health EOS Commercial |
$1,024.39
|
| Rate for Payer: HFN Commercial |
$1,058.92
|
| Rate for Payer: Multiplan Commercial |
$920.80
|
| Rate for Payer: NAPHCARE Commercial |
$690.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,058.92
|
| Rate for Payer: Quartz Beloit One Network |
$563.99
|
| Rate for Payer: Quartz Commercial |
$690.60
|
| Rate for Payer: WEA Trust Commercial |
$633.05
|
| Rate for Payer: WPS Commercial |
$852.55
|
|
|
EP LV Pacing & Recording +
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
CPT 93622
|
| Hospital Charge Code |
3052509
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$322.28 |
| Max. Negotiated Rate |
$29,139.00 |
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$989.86
|
| Rate for Payer: Aetna Managed Medicare |
$322.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$610.03
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cigna Commercial |
$1,058.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$644.10
|
| Rate for Payer: Health EOS Commercial |
$1,024.39
|
| Rate for Payer: HFN Commercial |
$1,058.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$863.25
|
| Rate for Payer: Multiplan Commercial |
$920.80
|
| Rate for Payer: NAPHCARE Commercial |
$690.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,058.92
|
| Rate for Payer: Quartz Beloit One Network |
$563.99
|
| Rate for Payer: Quartz Commercial |
$748.15
|
| Rate for Payer: Quartz Medicare Advantage |
$690.60
|
| Rate for Payer: The Alliance Commercial |
$4,604.00
|
| Rate for Payer: WEA Trust Commercial |
$633.05
|
| Rate for Payer: WPS Commercial |
$852.55
|
|
|
EPO / 100 Units Below
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3603551
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
EPO / 100 Units Below
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3603551
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
EPO / 100 Units Below PD
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3603569
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Aetna Managed Medicare |
$3.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7.20
|
| Rate for Payer: The Alliance Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
EPO / 100 Units Below PD
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3603569
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.20
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
EPO / 100 units (Dialysis)
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3005570
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
EPO / 100 units (Dialysis)
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3005570
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
EPO / 100 units (Peritoneal Dialysis)
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3026469
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
EPO / 100 units (Peritoneal Dialysis)
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3026469
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
