|
Inj, Penicillin G Benz and Pen G Procaine J0558
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
4027271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$18.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.02
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$18.51
|
| Rate for Payer: HFN Commercial |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19.14
|
| Rate for Payer: Quartz Beloit One Network |
$10.19
|
| Rate for Payer: Quartz Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$15.41
|
|
|
Inj, Penicillin G Benz and Pen G Procaine J0558
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
4027271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$55.83 |
| Rate for Payer: Aetna Commercial |
$19.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Aetna Managed Medicare |
$20.30
|
| Rate for Payer: Anthem Medicare Advantage |
$20.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.30
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.06
|
| Rate for Payer: Health EOS Commercial |
$18.93
|
| Rate for Payer: HFN Commercial |
$19.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.30
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: NAPHCARE Commercial |
$30.45
|
| Rate for Payer: Preferred Network Access Commercial |
$19.76
|
| Rate for Payer: Quartz Beloit One Network |
$9.15
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: Quartz Medicare Advantage |
$20.30
|
| Rate for Payer: The Alliance Commercial |
$55.83
|
| Rate for Payer: United Healthcare Medicaid |
$20.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.30
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$45.16
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$91.43 |
| Rate for Payer: Aetna Commercial |
$8.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$33.25
|
| Rate for Payer: Anthem Medicare Advantage |
$33.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.25
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.88
|
| Rate for Payer: Health EOS Commercial |
$8.52
|
| Rate for Payer: HFN Commercial |
$8.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.25
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$49.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8.89
|
| Rate for Payer: Quartz Beloit One Network |
$4.12
|
| Rate for Payer: Quartz Commercial |
$5.34
|
| Rate for Payer: Quartz Medicare Advantage |
$33.25
|
| Rate for Payer: The Alliance Commercial |
$91.43
|
| Rate for Payer: United Healthcare Medicaid |
$33.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.25
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$57.19
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$33.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Anthem Medicare Advantage |
$33.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.25
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33.25
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33.25
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$49.87
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$33.25
|
| Rate for Payer: The Alliance Commercial |
$133.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.25
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: Wellcare Medicare |
$33.25
|
| Rate for Payer: WPS Commercial |
$57.19
|
|
|
Inj Procedure For Ductogram
|
Professional
|
Both
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$39.85 |
| Max. Negotiated Rate |
$1,018.63 |
| Rate for Payer: Aetna Commercial |
$1,018.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$922.13
|
| Rate for Payer: Aetna Managed Medicare |
$62.68
|
| Rate for Payer: Anthem Medicare Advantage |
$62.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.68
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$1,018.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.68
|
| Rate for Payer: Health EOS Commercial |
$975.74
|
| Rate for Payer: HFN Commercial |
$1,018.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$267.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$267.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.68
|
| Rate for Payer: Multiplan Commercial |
$857.79
|
| Rate for Payer: NAPHCARE Commercial |
$94.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,018.63
|
| Rate for Payer: Quartz Beloit One Network |
$471.79
|
| Rate for Payer: Quartz Commercial |
$611.18
|
| Rate for Payer: Quartz Medicare Advantage |
$62.68
|
| Rate for Payer: The Alliance Commercial |
$266.39
|
| Rate for Payer: United Healthcare Medicaid |
$39.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.68
|
| Rate for Payer: WEA Trust Commercial |
$589.73
|
| Rate for Payer: WPS Commercial |
$282.06
|
|
|
Inj Procedure For Ductogram
|
Facility
|
IP
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$525.40 |
| Max. Negotiated Rate |
$986.46 |
| Rate for Payer: Aetna Commercial |
$965.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$922.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$568.29
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$986.46
|
| Rate for Payer: Health EOS Commercial |
$954.29
|
| Rate for Payer: HFN Commercial |
$986.46
|
| Rate for Payer: Multiplan Commercial |
$857.79
|
| Rate for Payer: Preferred Network Access Commercial |
$986.46
|
| Rate for Payer: Quartz Beloit One Network |
$525.40
|
| Rate for Payer: Quartz Commercial |
$643.34
|
| Rate for Payer: WEA Trust Commercial |
$589.73
|
| Rate for Payer: WPS Commercial |
$794.18
|
|
|
Inj Procedure For Ductogram
|
Facility
|
OP
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$250.72 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$965.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$922.13
|
| Rate for Payer: Aetna Managed Medicare |
$300.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$696.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$536.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$514.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$568.29
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$986.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$954.29
|
| Rate for Payer: HFN Commercial |
$986.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$804.18
|
| Rate for Payer: Multiplan Commercial |
$857.79
|
| Rate for Payer: NAPHCARE Commercial |
$643.34
|
| Rate for Payer: Preferred Network Access Commercial |
$986.46
|
| Rate for Payer: Quartz Beloit One Network |
$525.40
|
| Rate for Payer: Quartz Commercial |
$696.96
|
| Rate for Payer: Quartz Medicare Advantage |
$643.34
|
| Rate for Payer: The Alliance Commercial |
$250.72
|
| Rate for Payer: WEA Trust Commercial |
$589.73
|
| Rate for Payer: WPS Commercial |
$794.18
|
|
|
Inj Procedure Venogram
|
Professional
|
Both
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$39.34 |
| Max. Negotiated Rate |
$1,300.21 |
| Rate for Payer: Aetna Commercial |
$1,300.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,177.03
|
| Rate for Payer: Aetna Managed Medicare |
$39.34
|
| Rate for Payer: Anthem Medicare Advantage |
$39.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.34
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,300.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.34
|
| Rate for Payer: Health EOS Commercial |
$1,245.46
|
| Rate for Payer: HFN Commercial |
$1,300.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$163.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.34
|
| Rate for Payer: Multiplan Commercial |
$1,094.91
|
| Rate for Payer: NAPHCARE Commercial |
$59.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,300.21
|
| Rate for Payer: Quartz Beloit One Network |
$602.20
|
| Rate for Payer: Quartz Commercial |
$780.12
|
| Rate for Payer: Quartz Medicare Advantage |
$39.34
|
| Rate for Payer: The Alliance Commercial |
$167.21
|
| Rate for Payer: United Healthcare Medicaid |
$52.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.34
|
| Rate for Payer: WEA Trust Commercial |
$752.75
|
| Rate for Payer: WPS Commercial |
$177.04
|
|
|
Inj Procedure Venogram
|
Facility
|
OP
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$157.37 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$1,231.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,177.03
|
| Rate for Payer: Aetna Managed Medicare |
$383.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$889.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$684.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$656.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$725.38
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,259.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$1,218.09
|
| Rate for Payer: HFN Commercial |
$1,259.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,026.48
|
| Rate for Payer: Multiplan Commercial |
$1,094.91
|
| Rate for Payer: NAPHCARE Commercial |
$821.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,259.15
|
| Rate for Payer: Quartz Beloit One Network |
$670.63
|
| Rate for Payer: Quartz Commercial |
$889.62
|
| Rate for Payer: Quartz Medicare Advantage |
$821.18
|
| Rate for Payer: The Alliance Commercial |
$157.37
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$752.75
|
| Rate for Payer: WPS Commercial |
$1,013.71
|
|
|
Inj Procedure Venogram
|
Facility
|
IP
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$670.63 |
| Max. Negotiated Rate |
$1,259.15 |
| Rate for Payer: Aetna Commercial |
$1,231.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,177.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$725.38
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,259.15
|
| Rate for Payer: Health EOS Commercial |
$1,218.09
|
| Rate for Payer: HFN Commercial |
$1,259.15
|
| Rate for Payer: Multiplan Commercial |
$1,094.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,259.15
|
| Rate for Payer: Quartz Beloit One Network |
$670.63
|
| Rate for Payer: Quartz Commercial |
$821.18
|
| Rate for Payer: WEA Trust Commercial |
$752.75
|
| Rate for Payer: WPS Commercial |
$1,013.71
|
|
|
Inj PTC
|
Facility
|
IP
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,614.41 |
| Max. Negotiated Rate |
$3,031.14 |
| Rate for Payer: Aetna Commercial |
$2,965.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,746.20
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,031.14
|
| Rate for Payer: Health EOS Commercial |
$2,932.30
|
| Rate for Payer: HFN Commercial |
$3,031.14
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,031.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.41
|
| Rate for Payer: Quartz Commercial |
$1,976.83
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Inj PTC
|
Facility
|
OP
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$922.52 |
| Max. Negotiated Rate |
$3,031.14 |
| Rate for Payer: Aetna Commercial |
$2,965.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Aetna Managed Medicare |
$922.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,141.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,647.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,581.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,746.20
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,031.14
|
| Rate for Payer: Health EOS Commercial |
$2,932.30
|
| Rate for Payer: HFN Commercial |
$3,031.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,471.04
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,976.83
|
| Rate for Payer: Preferred Network Access Commercial |
$3,031.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,614.41
|
| Rate for Payer: Quartz Commercial |
$2,141.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,976.83
|
| Rate for Payer: The Alliance Commercial |
$1,647.36
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Inj PTC
|
Professional
|
Both
|
$3,168.00
|
|
|
Service Code
|
CPT 47500
|
| Hospital Charge Code |
3072743
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,449.68 |
| Max. Negotiated Rate |
$3,129.98 |
| Rate for Payer: Aetna Commercial |
$3,129.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,833.46
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Cigna Commercial |
$3,129.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,647.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,976.83
|
| Rate for Payer: Health EOS Commercial |
$2,998.20
|
| Rate for Payer: HFN Commercial |
$3,129.98
|
| Rate for Payer: Multiplan Commercial |
$2,635.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,129.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.68
|
| Rate for Payer: Quartz Commercial |
$1,877.99
|
| Rate for Payer: The Alliance Commercial |
$1,647.36
|
| Rate for Payer: WEA Trust Commercial |
$1,812.10
|
| Rate for Payer: WPS Commercial |
$2,440.31
|
|
|
Inj Pyelopgraphy
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$333.72 |
| Max. Negotiated Rate |
$1,096.49 |
| Rate for Payer: Aetna Commercial |
$1,072.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.98
|
| Rate for Payer: Aetna Managed Medicare |
$333.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$774.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$595.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$572.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.68
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,096.49
|
| Rate for Payer: Health EOS Commercial |
$1,060.74
|
| Rate for Payer: HFN Commercial |
$1,096.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$893.88
|
| Rate for Payer: Multiplan Commercial |
$953.47
|
| Rate for Payer: NAPHCARE Commercial |
$715.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.49
|
| Rate for Payer: Quartz Beloit One Network |
$584.00
|
| Rate for Payer: Quartz Commercial |
$774.70
|
| Rate for Payer: Quartz Medicare Advantage |
$715.10
|
| Rate for Payer: The Alliance Commercial |
$595.92
|
| Rate for Payer: WEA Trust Commercial |
$655.51
|
| Rate for Payer: WPS Commercial |
$882.76
|
|
|
Inj Pyelopgraphy
|
Professional
|
Both
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$524.41 |
| Max. Negotiated Rate |
$1,132.25 |
| Rate for Payer: Aetna Commercial |
$1,132.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.98
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,132.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$595.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$715.10
|
| Rate for Payer: Health EOS Commercial |
$1,084.57
|
| Rate for Payer: HFN Commercial |
$1,132.25
|
| Rate for Payer: Multiplan Commercial |
$953.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,132.25
|
| Rate for Payer: Quartz Beloit One Network |
$524.41
|
| Rate for Payer: Quartz Commercial |
$679.35
|
| Rate for Payer: The Alliance Commercial |
$595.92
|
| Rate for Payer: WEA Trust Commercial |
$655.51
|
| Rate for Payer: WPS Commercial |
$882.76
|
|
|
Inj Pyelopgraphy
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
CPT 50394
|
| Hospital Charge Code |
3072747
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$584.00 |
| Max. Negotiated Rate |
$1,096.49 |
| Rate for Payer: Aetna Commercial |
$1,072.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$631.68
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$1,096.49
|
| Rate for Payer: Health EOS Commercial |
$1,060.74
|
| Rate for Payer: HFN Commercial |
$1,096.49
|
| Rate for Payer: Multiplan Commercial |
$953.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.49
|
| Rate for Payer: Quartz Beloit One Network |
$584.00
|
| Rate for Payer: Quartz Commercial |
$715.10
|
| Rate for Payer: WEA Trust Commercial |
$655.51
|
| Rate for Payer: WPS Commercial |
$882.76
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Facility
|
IP
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$399.53 |
| Max. Negotiated Rate |
$750.13 |
| Rate for Payer: Aetna Commercial |
$733.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$701.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$432.14
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$750.13
|
| Rate for Payer: Health EOS Commercial |
$725.67
|
| Rate for Payer: HFN Commercial |
$750.13
|
| Rate for Payer: Multiplan Commercial |
$652.29
|
| Rate for Payer: Preferred Network Access Commercial |
$750.13
|
| Rate for Payer: Quartz Beloit One Network |
$399.53
|
| Rate for Payer: Quartz Commercial |
$489.22
|
| Rate for Payer: WEA Trust Commercial |
$448.45
|
| Rate for Payer: WPS Commercial |
$603.92
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Professional
|
Both
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$358.76 |
| Max. Negotiated Rate |
$774.59 |
| Rate for Payer: Aetna Commercial |
$774.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$701.21
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$774.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$407.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$489.22
|
| Rate for Payer: Health EOS Commercial |
$741.98
|
| Rate for Payer: HFN Commercial |
$774.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$642.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$642.57
|
| Rate for Payer: Multiplan Commercial |
$652.29
|
| Rate for Payer: Preferred Network Access Commercial |
$774.59
|
| Rate for Payer: Quartz Beloit One Network |
$358.76
|
| Rate for Payer: Quartz Commercial |
$464.76
|
| Rate for Payer: The Alliance Commercial |
$407.68
|
| Rate for Payer: WEA Trust Commercial |
$448.45
|
| Rate for Payer: WPS Commercial |
$603.92
|
|
|
Inj (s), diag, or TA, Parav Facet 0216T50
|
Facility
|
OP
|
$784.00
|
|
|
Service Code
|
CPT 0216T 50
|
| Hospital Charge Code |
3382932
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$228.30 |
| Max. Negotiated Rate |
$3,030.56 |
| Rate for Payer: Aetna Commercial |
$733.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$701.21
|
| Rate for Payer: Aetna Managed Medicare |
$228.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$432.14
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cigna Commercial |
$750.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$456.29
|
| Rate for Payer: Health EOS Commercial |
$725.67
|
| Rate for Payer: HFN Commercial |
$750.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$611.52
|
| Rate for Payer: Multiplan Commercial |
$652.29
|
| Rate for Payer: NAPHCARE Commercial |
$489.22
|
| Rate for Payer: Preferred Network Access Commercial |
$750.13
|
| Rate for Payer: Quartz Beloit One Network |
$399.53
|
| Rate for Payer: Quartz Commercial |
$529.98
|
| Rate for Payer: Quartz Medicare Advantage |
$489.22
|
| Rate for Payer: The Alliance Commercial |
$407.68
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: WEA Trust Commercial |
$448.45
|
| Rate for Payer: WPS Commercial |
$603.92
|
|
|
Inj Shoulder Arthrography
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$165.32 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$165.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$383.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$283.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$443.04
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$354.43
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$383.97
|
| Rate for Payer: Quartz Medicare Advantage |
$354.43
|
| Rate for Payer: The Alliance Commercial |
$165.32
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
Inj Shoulder Arthrography
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$41.33 |
| Max. Negotiated Rate |
$561.18 |
| Rate for Payer: Aetna Commercial |
$561.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$41.33
|
| Rate for Payer: Anthem Medicare Advantage |
$41.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.33
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$561.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.33
|
| Rate for Payer: Health EOS Commercial |
$537.56
|
| Rate for Payer: HFN Commercial |
$561.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$176.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.33
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$61.99
|
| Rate for Payer: Preferred Network Access Commercial |
$561.18
|
| Rate for Payer: Quartz Beloit One Network |
$259.92
|
| Rate for Payer: Quartz Commercial |
$336.71
|
| Rate for Payer: Quartz Medicare Advantage |
$41.33
|
| Rate for Payer: The Alliance Commercial |
$175.65
|
| Rate for Payer: United Healthcare Medicaid |
$42.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.33
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$185.98
|
|
|
Inj Shoulder Arthrography
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
3072740
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$289.45 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$354.43
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
Inj SI Joint Arthrgrphy &/Anes 27096
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
CPT 27096
|
| Hospital Charge Code |
5232766
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.49 |
| Max. Negotiated Rate |
$326.20 |
| Rate for Payer: Aetna Commercial |
$259.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.23
|
| Rate for Payer: Aetna Managed Medicare |
$72.49
|
| Rate for Payer: Anthem Medicare Advantage |
$72.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.49
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$259.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.49
|
| Rate for Payer: Health EOS Commercial |
$248.90
|
| Rate for Payer: HFN Commercial |
$259.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.49
|
| Rate for Payer: Multiplan Commercial |
$218.82
|
| Rate for Payer: NAPHCARE Commercial |
$108.73
|
| Rate for Payer: Preferred Network Access Commercial |
$259.84
|
| Rate for Payer: Quartz Beloit One Network |
$120.35
|
| Rate for Payer: Quartz Commercial |
$155.91
|
| Rate for Payer: Quartz Medicare Advantage |
$72.49
|
| Rate for Payer: The Alliance Commercial |
$308.07
|
| Rate for Payer: United Healthcare Medicaid |
$157.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.49
|
| Rate for Payer: WEA Trust Commercial |
$150.44
|
| Rate for Payer: WPS Commercial |
$326.20
|
|
|
Inj SI Joint Arthrgrphy &/Anes 2709650
|
Professional
|
Both
|
$826.00
|
|
|
Service Code
|
CPT 27096 50
|
| Hospital Charge Code |
5273237
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$157.38 |
| Max. Negotiated Rate |
$816.09 |
| Rate for Payer: Aetna Commercial |
$816.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$738.77
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cash Price |
$247.80
|
| Rate for Payer: Cigna Commercial |
$816.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$515.42
|
| Rate for Payer: Health EOS Commercial |
$781.73
|
| Rate for Payer: HFN Commercial |
$816.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.64
|
| Rate for Payer: Multiplan Commercial |
$687.23
|
| Rate for Payer: Preferred Network Access Commercial |
$816.09
|
| Rate for Payer: Quartz Beloit One Network |
$377.98
|
| Rate for Payer: Quartz Commercial |
$489.65
|
| Rate for Payer: The Alliance Commercial |
$429.52
|
| Rate for Payer: United Healthcare Medicaid |
$157.38
|
| Rate for Payer: WEA Trust Commercial |
$472.47
|
| Rate for Payer: WPS Commercial |
$636.27
|
|
