|
ILIAC LIMB
|
Facility
|
IP
|
$23,002.00
|
|
| Hospital Charge Code |
2970591
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,721.82 |
| Max. Negotiated Rate |
$22,008.31 |
| Rate for Payer: Aetna Commercial |
$21,529.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20,572.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,678.70
|
| Rate for Payer: Cash Price |
$6,900.60
|
| Rate for Payer: Cigna Commercial |
$22,008.31
|
| Rate for Payer: Health EOS Commercial |
$21,290.65
|
| Rate for Payer: HFN Commercial |
$22,008.31
|
| Rate for Payer: Multiplan Commercial |
$19,137.66
|
| Rate for Payer: Preferred Network Access Commercial |
$22,008.31
|
| Rate for Payer: Quartz Beloit One Network |
$11,721.82
|
| Rate for Payer: Quartz Commercial |
$14,353.25
|
| Rate for Payer: WEA Trust Commercial |
$13,157.14
|
| Rate for Payer: WPS Commercial |
$17,718.44
|
|
|
ILIAC LIMB GRAFT PXA260300
|
Facility
|
IP
|
$17,360.00
|
|
| Hospital Charge Code |
2973921
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,846.66 |
| Max. Negotiated Rate |
$16,610.05 |
| Rate for Payer: Aetna Commercial |
$16,248.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,526.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,568.83
|
| Rate for Payer: Cash Price |
$5,208.00
|
| Rate for Payer: Cigna Commercial |
$16,610.05
|
| Rate for Payer: Health EOS Commercial |
$16,068.42
|
| Rate for Payer: HFN Commercial |
$16,610.05
|
| Rate for Payer: Multiplan Commercial |
$14,443.52
|
| Rate for Payer: Preferred Network Access Commercial |
$16,610.05
|
| Rate for Payer: Quartz Beloit One Network |
$8,846.66
|
| Rate for Payer: Quartz Commercial |
$10,832.64
|
| Rate for Payer: WEA Trust Commercial |
$9,929.92
|
| Rate for Payer: WPS Commercial |
$13,372.41
|
|
|
ILIAC LIMB GRAFT PXA260300
|
Facility
|
OP
|
$17,360.00
|
|
| Hospital Charge Code |
2973921
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,055.23 |
| Max. Negotiated Rate |
$16,610.05 |
| Rate for Payer: Aetna Commercial |
$16,248.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,526.78
|
| Rate for Payer: Aetna Managed Medicare |
$5,055.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,735.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,027.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,666.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,568.83
|
| Rate for Payer: Cash Price |
$5,208.00
|
| Rate for Payer: Cigna Commercial |
$16,610.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,103.52
|
| Rate for Payer: Health EOS Commercial |
$16,068.42
|
| Rate for Payer: HFN Commercial |
$16,610.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,540.80
|
| Rate for Payer: Multiplan Commercial |
$14,443.52
|
| Rate for Payer: NAPHCARE Commercial |
$10,832.64
|
| Rate for Payer: Preferred Network Access Commercial |
$16,610.05
|
| Rate for Payer: Quartz Beloit One Network |
$8,846.66
|
| Rate for Payer: Quartz Commercial |
$11,735.36
|
| Rate for Payer: Quartz Medicare Advantage |
$10,832.64
|
| Rate for Payer: The Alliance Commercial |
$9,027.20
|
| Rate for Payer: WEA Trust Commercial |
$9,929.92
|
| Rate for Payer: WPS Commercial |
$13,372.41
|
|
|
ILIAC LIMB PXC161200
|
Facility
|
IP
|
$21,910.00
|
|
| Hospital Charge Code |
2973939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,165.34 |
| Max. Negotiated Rate |
$20,963.49 |
| Rate for Payer: Aetna Commercial |
$20,507.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,596.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,076.79
|
| Rate for Payer: Cash Price |
$6,573.00
|
| Rate for Payer: Cigna Commercial |
$20,963.49
|
| Rate for Payer: Health EOS Commercial |
$20,279.90
|
| Rate for Payer: HFN Commercial |
$20,963.49
|
| Rate for Payer: Multiplan Commercial |
$18,229.12
|
| Rate for Payer: Preferred Network Access Commercial |
$20,963.49
|
| Rate for Payer: Quartz Beloit One Network |
$11,165.34
|
| Rate for Payer: Quartz Commercial |
$13,671.84
|
| Rate for Payer: WEA Trust Commercial |
$12,532.52
|
| Rate for Payer: WPS Commercial |
$16,877.27
|
|
|
ILIAC LIMB PXC161200
|
Facility
|
OP
|
$21,910.00
|
|
| Hospital Charge Code |
2973939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,380.19 |
| Max. Negotiated Rate |
$20,963.49 |
| Rate for Payer: Aetna Commercial |
$20,507.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,596.30
|
| Rate for Payer: Aetna Managed Medicare |
$6,380.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,811.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,393.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,937.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,076.79
|
| Rate for Payer: Cash Price |
$6,573.00
|
| Rate for Payer: Cigna Commercial |
$20,963.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,751.62
|
| Rate for Payer: Health EOS Commercial |
$20,279.90
|
| Rate for Payer: HFN Commercial |
$20,963.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,089.80
|
| Rate for Payer: Multiplan Commercial |
$18,229.12
|
| Rate for Payer: NAPHCARE Commercial |
$13,671.84
|
| Rate for Payer: Preferred Network Access Commercial |
$20,963.49
|
| Rate for Payer: Quartz Beloit One Network |
$11,165.34
|
| Rate for Payer: Quartz Commercial |
$14,811.16
|
| Rate for Payer: Quartz Medicare Advantage |
$13,671.84
|
| Rate for Payer: The Alliance Commercial |
$11,393.20
|
| Rate for Payer: WEA Trust Commercial |
$12,532.52
|
| Rate for Payer: WPS Commercial |
$16,877.27
|
|
|
ILIAC LYMPHADENECTOMY
|
Facility
|
OP
|
$7,388.00
|
|
| Hospital Charge Code |
2960149
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,151.39 |
| Max. Negotiated Rate |
$7,068.84 |
| Rate for Payer: Aetna Commercial |
$6,915.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,607.83
|
| Rate for Payer: Aetna Managed Medicare |
$2,151.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,994.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,841.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,688.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,072.27
|
| Rate for Payer: Cash Price |
$2,216.40
|
| Rate for Payer: Cigna Commercial |
$7,068.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,299.82
|
| Rate for Payer: Health EOS Commercial |
$6,838.33
|
| Rate for Payer: HFN Commercial |
$7,068.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,762.64
|
| Rate for Payer: Multiplan Commercial |
$6,146.82
|
| Rate for Payer: NAPHCARE Commercial |
$4,610.11
|
| Rate for Payer: Preferred Network Access Commercial |
$7,068.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,764.92
|
| Rate for Payer: Quartz Commercial |
$4,994.29
|
| Rate for Payer: Quartz Medicare Advantage |
$4,610.11
|
| Rate for Payer: The Alliance Commercial |
$3,841.76
|
| Rate for Payer: WEA Trust Commercial |
$4,225.94
|
| Rate for Payer: WPS Commercial |
$5,690.98
|
|
|
ILIAC LYMPHADENECTOMY
|
Facility
|
IP
|
$7,388.00
|
|
| Hospital Charge Code |
2960149
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,764.92 |
| Max. Negotiated Rate |
$7,068.84 |
| Rate for Payer: Aetna Commercial |
$6,915.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,607.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,072.27
|
| Rate for Payer: Cash Price |
$2,216.40
|
| Rate for Payer: Cigna Commercial |
$7,068.84
|
| Rate for Payer: Health EOS Commercial |
$6,838.33
|
| Rate for Payer: HFN Commercial |
$7,068.84
|
| Rate for Payer: Multiplan Commercial |
$6,146.82
|
| Rate for Payer: Preferred Network Access Commercial |
$7,068.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,764.92
|
| Rate for Payer: Quartz Commercial |
$4,610.11
|
| Rate for Payer: WEA Trust Commercial |
$4,225.94
|
| Rate for Payer: WPS Commercial |
$5,690.98
|
|
|
Iloperidone Level
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$184.62 |
| Max. Negotiated Rate |
$606.61 |
| Rate for Payer: Aetna Commercial |
$593.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Aetna Managed Medicare |
$184.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$428.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$329.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$316.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.46
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$606.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$368.99
|
| Rate for Payer: Health EOS Commercial |
$586.83
|
| Rate for Payer: HFN Commercial |
$606.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$494.52
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: NAPHCARE Commercial |
$395.62
|
| Rate for Payer: Preferred Network Access Commercial |
$606.61
|
| Rate for Payer: Quartz Beloit One Network |
$323.09
|
| Rate for Payer: Quartz Commercial |
$428.58
|
| Rate for Payer: Quartz Medicare Advantage |
$395.62
|
| Rate for Payer: The Alliance Commercial |
$329.68
|
| Rate for Payer: United Healthcare PPO |
$494.52
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Iloperidone Level
|
Professional
|
Both
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$626.39 |
| Rate for Payer: Aetna Commercial |
$626.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$626.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$329.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$395.62
|
| Rate for Payer: Health EOS Commercial |
$600.02
|
| Rate for Payer: HFN Commercial |
$626.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: Preferred Network Access Commercial |
$626.39
|
| Rate for Payer: Quartz Beloit One Network |
$290.12
|
| Rate for Payer: Quartz Commercial |
$375.84
|
| Rate for Payer: The Alliance Commercial |
$329.68
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Iloperidone Level
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
5581590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$323.09 |
| Max. Negotiated Rate |
$606.61 |
| Rate for Payer: Aetna Commercial |
$593.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$567.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.46
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$586.83
|
| Rate for Payer: HFN Commercial |
$606.61
|
| Rate for Payer: Multiplan Commercial |
$527.49
|
| Rate for Payer: Preferred Network Access Commercial |
$606.61
|
| Rate for Payer: Quartz Beloit One Network |
$323.09
|
| Rate for Payer: Quartz Commercial |
$395.62
|
| Rate for Payer: WEA Trust Commercial |
$362.65
|
| Rate for Payer: WPS Commercial |
$488.37
|
|
|
Image Fusion RT
|
Facility
|
OP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$213.16 |
| Max. Negotiated Rate |
$3,333.20 |
| Rate for Payer: Aetna Commercial |
$685.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$654.70
|
| Rate for Payer: Aetna Managed Medicare |
$213.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,689.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,552.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$403.48
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cigna Commercial |
$700.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.02
|
| Rate for Payer: Health EOS Commercial |
$677.54
|
| Rate for Payer: HFN Commercial |
$700.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$570.96
|
| Rate for Payer: Multiplan Commercial |
$609.02
|
| Rate for Payer: NAPHCARE Commercial |
$456.77
|
| Rate for Payer: Preferred Network Access Commercial |
$700.38
|
| Rate for Payer: Quartz Beloit One Network |
$373.03
|
| Rate for Payer: Quartz Commercial |
$494.83
|
| Rate for Payer: Quartz Medicare Advantage |
$456.77
|
| Rate for Payer: The Alliance Commercial |
$312.33
|
| Rate for Payer: United Healthcare PPO |
$2,147.60
|
| Rate for Payer: WEA Trust Commercial |
$418.70
|
| Rate for Payer: WPS Commercial |
$546.58
|
|
|
Image Fusion RT
|
Facility
|
IP
|
$732.00
|
|
|
Service Code
|
CPT 76377
|
| Hospital Charge Code |
3040410
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$373.03 |
| Max. Negotiated Rate |
$700.38 |
| Rate for Payer: Aetna Commercial |
$685.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$654.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$403.48
|
| Rate for Payer: Cash Price |
$219.60
|
| Rate for Payer: Cigna Commercial |
$700.38
|
| Rate for Payer: Health EOS Commercial |
$677.54
|
| Rate for Payer: HFN Commercial |
$700.38
|
| Rate for Payer: Multiplan Commercial |
$609.02
|
| Rate for Payer: Preferred Network Access Commercial |
$700.38
|
| Rate for Payer: Quartz Beloit One Network |
$373.03
|
| Rate for Payer: Quartz Commercial |
$456.77
|
| Rate for Payer: WEA Trust Commercial |
$418.70
|
| Rate for Payer: WPS Commercial |
$563.86
|
|
|
Imaging Guidance RT
|
Facility
|
OP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$146.35 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Aetna Managed Medicare |
$355.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$825.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$634.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$609.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$710.62
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$952.38
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: NAPHCARE Commercial |
$761.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$825.40
|
| Rate for Payer: Quartz Medicare Advantage |
$761.90
|
| Rate for Payer: The Alliance Commercial |
$146.35
|
| Rate for Payer: United Healthcare PPO |
$952.38
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
Imaging Guidance RT
|
Facility
|
IP
|
$1,221.00
|
|
|
Service Code
|
CPT 77387
|
| Hospital Charge Code |
3883521
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$622.22 |
| Max. Negotiated Rate |
$1,168.25 |
| Rate for Payer: Aetna Commercial |
$1,142.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,092.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$673.02
|
| Rate for Payer: Cash Price |
$366.30
|
| Rate for Payer: Cigna Commercial |
$1,168.25
|
| Rate for Payer: Health EOS Commercial |
$1,130.16
|
| Rate for Payer: HFN Commercial |
$1,168.25
|
| Rate for Payer: Multiplan Commercial |
$1,015.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,168.25
|
| Rate for Payer: Quartz Beloit One Network |
$622.22
|
| Rate for Payer: Quartz Commercial |
$761.90
|
| Rate for Payer: WEA Trust Commercial |
$698.41
|
| Rate for Payer: WPS Commercial |
$940.54
|
|
|
Imipramine Level
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$473.25 |
| Rate for Payer: Aetna Commercial |
$473.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$473.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.90
|
| Rate for Payer: Health EOS Commercial |
$453.33
|
| Rate for Payer: HFN Commercial |
$473.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$473.25
|
| Rate for Payer: Quartz Beloit One Network |
$219.19
|
| Rate for Payer: Quartz Commercial |
$283.95
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imipramine Level
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.48 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Aetna Managed Medicare |
$139.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.78
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.62
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: NAPHCARE Commercial |
$298.90
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$323.80
|
| Rate for Payer: Quartz Medicare Advantage |
$298.90
|
| Rate for Payer: The Alliance Commercial |
$249.08
|
| Rate for Payer: United Healthcare PPO |
$373.62
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imipramine Level
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977992
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$458.31 |
| Rate for Payer: Aetna Commercial |
$448.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.02
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$458.31
|
| Rate for Payer: Health EOS Commercial |
$443.36
|
| Rate for Payer: HFN Commercial |
$458.31
|
| Rate for Payer: Multiplan Commercial |
$398.53
|
| Rate for Payer: Preferred Network Access Commercial |
$458.31
|
| Rate for Payer: Quartz Beloit One Network |
$244.10
|
| Rate for Payer: Quartz Commercial |
$298.90
|
| Rate for Payer: WEA Trust Commercial |
$273.99
|
| Rate for Payer: WPS Commercial |
$368.97
|
|
|
Imitrex 6 mg Charge
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$161.04 |
| Rate for Payer: Aetna Commercial |
$161.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$161.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.71
|
| Rate for Payer: Health EOS Commercial |
$154.26
|
| Rate for Payer: HFN Commercial |
$161.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$90.51
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$161.04
|
| Rate for Payer: Quartz Beloit One Network |
$74.59
|
| Rate for Payer: Quartz Commercial |
$96.63
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: United Healthcare Medicaid |
$53.97
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Imitrex 6 mg Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.87
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$84.76
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
Imitrex 6 mg Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
2958975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
IMMOBILIZER HEAD STA-BLOK 700-00001
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2963960
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
IMMUNE ADMIN ORAL/NASAL 90473
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
CPT 90473
|
| Hospital Charge Code |
3015323
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$69.31 |
| Rate for Payer: Aetna Commercial |
$28.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$17.33
|
| Rate for Payer: Anthem Medicare Advantage |
$17.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.33
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$28.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.33
|
| Rate for Payer: Health EOS Commercial |
$27.45
|
| Rate for Payer: HFN Commercial |
$28.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.33
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$25.99
|
| Rate for Payer: Preferred Network Access Commercial |
$28.65
|
| Rate for Payer: Quartz Beloit One Network |
$13.27
|
| Rate for Payer: Quartz Commercial |
$17.19
|
| Rate for Payer: Quartz Medicare Advantage |
$17.33
|
| Rate for Payer: The Alliance Commercial |
$43.32
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.33
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$69.31
|
|
|
Immune Admin Oral/Nasal Addl 90474
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 90474
|
| Hospital Charge Code |
3507508
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Immune Admin Oral/Nasal Addl 90474
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 90474
|
| Hospital Charge Code |
3507508
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$49.21 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Aetna Managed Medicare |
$14.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.56
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$47.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Health EOS Commercial |
$46.28
|
| Rate for Payer: HFN Commercial |
$47.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.00
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: NAPHCARE Commercial |
$31.20
|
| Rate for Payer: Preferred Network Access Commercial |
$47.84
|
| Rate for Payer: Quartz Beloit One Network |
$25.48
|
| Rate for Payer: Quartz Commercial |
$33.80
|
| Rate for Payer: Quartz Medicare Advantage |
$31.20
|
| Rate for Payer: The Alliance Commercial |
$49.21
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
