|
Inj Sinogram
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$30.45 |
| Max. Negotiated Rate |
$840.79 |
| Rate for Payer: Aetna Commercial |
$840.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$761.13
|
| Rate for Payer: Aetna Managed Medicare |
$30.45
|
| Rate for Payer: Anthem Medicare Advantage |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.45
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$840.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.45
|
| Rate for Payer: Health EOS Commercial |
$805.39
|
| Rate for Payer: HFN Commercial |
$840.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.45
|
| Rate for Payer: Multiplan Commercial |
$708.03
|
| Rate for Payer: NAPHCARE Commercial |
$45.68
|
| Rate for Payer: Preferred Network Access Commercial |
$840.79
|
| Rate for Payer: Quartz Beloit One Network |
$389.42
|
| Rate for Payer: Quartz Commercial |
$504.47
|
| Rate for Payer: Quartz Medicare Advantage |
$30.45
|
| Rate for Payer: The Alliance Commercial |
$129.42
|
| Rate for Payer: United Healthcare Medicaid |
$44.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.45
|
| Rate for Payer: WEA Trust Commercial |
$486.77
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
Inj Sinogram
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$796.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$761.13
|
| Rate for Payer: Aetna Managed Medicare |
$247.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$575.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$469.07
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$814.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$787.69
|
| Rate for Payer: HFN Commercial |
$814.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.78
|
| Rate for Payer: Multiplan Commercial |
$708.03
|
| Rate for Payer: NAPHCARE Commercial |
$531.02
|
| Rate for Payer: Preferred Network Access Commercial |
$814.24
|
| Rate for Payer: Quartz Beloit One Network |
$433.67
|
| Rate for Payer: Quartz Commercial |
$575.28
|
| Rate for Payer: Quartz Medicare Advantage |
$531.02
|
| Rate for Payer: The Alliance Commercial |
$121.80
|
| Rate for Payer: WEA Trust Commercial |
$486.77
|
| Rate for Payer: WPS Commercial |
$655.53
|
|
|
Inj Sinogram
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
CPT 20501
|
| Hospital Charge Code |
3072750
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$433.67 |
| Max. Negotiated Rate |
$814.24 |
| Rate for Payer: Aetna Commercial |
$796.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$761.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$469.07
|
| Rate for Payer: Cash Price |
$255.30
|
| Rate for Payer: Cigna Commercial |
$814.24
|
| Rate for Payer: Health EOS Commercial |
$787.69
|
| Rate for Payer: HFN Commercial |
$814.24
|
| Rate for Payer: Multiplan Commercial |
$708.03
|
| Rate for Payer: Preferred Network Access Commercial |
$814.24
|
| Rate for Payer: Quartz Beloit One Network |
$433.67
|
| Rate for Payer: Quartz Commercial |
$531.02
|
| Rate for Payer: WEA Trust Commercial |
$486.77
|
| Rate for Payer: WPS Commercial |
$655.53
|
|
|
Inj Tendon Sheath/Ligament 20550
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
4494905
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$145.41 |
| Rate for Payer: Aetna Commercial |
$86.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$32.31
|
| Rate for Payer: Anthem Medicare Advantage |
$32.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.31
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$86.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.31
|
| Rate for Payer: Health EOS Commercial |
$83.28
|
| Rate for Payer: HFN Commercial |
$86.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.31
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$48.47
|
| Rate for Payer: Preferred Network Access Commercial |
$86.94
|
| Rate for Payer: Quartz Beloit One Network |
$40.27
|
| Rate for Payer: Quartz Commercial |
$52.17
|
| Rate for Payer: Quartz Medicare Advantage |
$32.31
|
| Rate for Payer: The Alliance Commercial |
$137.33
|
| Rate for Payer: United Healthcare Medicaid |
$28.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.31
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$145.41
|
|
|
Inj Tendon Sheath/Ligament 2055050
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 20550 50
|
| Hospital Charge Code |
3850018
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$175.86 |
| Rate for Payer: Aetna Commercial |
$175.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$175.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.07
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$175.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.69
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$175.86
|
| Rate for Payer: Quartz Beloit One Network |
$81.45
|
| Rate for Payer: Quartz Commercial |
$105.52
|
| Rate for Payer: The Alliance Commercial |
$92.56
|
| Rate for Payer: United Healthcare Medicaid |
$28.05
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
Inj Treatment Nerve 64600
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
CPT 64600
|
| Hospital Charge Code |
5232708
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$205.46 |
| Max. Negotiated Rate |
$947.14 |
| Rate for Payer: Aetna Commercial |
$443.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Aetna Managed Medicare |
$210.48
|
| Rate for Payer: Anthem Medicare Advantage |
$210.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.48
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$443.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$762.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.48
|
| Rate for Payer: Health EOS Commercial |
$424.93
|
| Rate for Payer: HFN Commercial |
$443.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$779.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$779.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.48
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: NAPHCARE Commercial |
$315.71
|
| Rate for Payer: Preferred Network Access Commercial |
$443.61
|
| Rate for Payer: Quartz Beloit One Network |
$205.46
|
| Rate for Payer: Quartz Commercial |
$266.17
|
| Rate for Payer: Quartz Medicare Advantage |
$210.48
|
| Rate for Payer: The Alliance Commercial |
$894.52
|
| Rate for Payer: United Healthcare Medicaid |
$762.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.48
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: WPS Commercial |
$947.14
|
|
|
Inj T-Tube Cholangiogram
|
Facility
|
IP
|
$1,631.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
3072742
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$831.16 |
| Max. Negotiated Rate |
$1,560.54 |
| Rate for Payer: Aetna Commercial |
$1,526.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,458.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.01
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,560.54
|
| Rate for Payer: Health EOS Commercial |
$1,509.65
|
| Rate for Payer: HFN Commercial |
$1,560.54
|
| Rate for Payer: Multiplan Commercial |
$1,356.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,560.54
|
| Rate for Payer: Quartz Beloit One Network |
$831.16
|
| Rate for Payer: Quartz Commercial |
$1,017.74
|
| Rate for Payer: WEA Trust Commercial |
$932.93
|
| Rate for Payer: WPS Commercial |
$1,256.36
|
|
|
Inj T-Tube Cholangiogram
|
Facility
|
OP
|
$1,631.00
|
|
|
Service Code
|
CPT 47531
|
| Hospital Charge Code |
3072742
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$831.16 |
| Max. Negotiated Rate |
$15,071.89 |
| Rate for Payer: Aetna Commercial |
$1,526.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,458.77
|
| Rate for Payer: Aetna Managed Medicare |
$3,767.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,767.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,767.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,767.97
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,560.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,767.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,767.97
|
| Rate for Payer: Health EOS Commercial |
$1,509.65
|
| Rate for Payer: HFN Commercial |
$1,560.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,016.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,767.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,767.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,767.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,767.97
|
| Rate for Payer: Multiplan Commercial |
$1,356.99
|
| Rate for Payer: NAPHCARE Commercial |
$5,651.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,560.54
|
| Rate for Payer: Quartz Beloit One Network |
$831.16
|
| Rate for Payer: Quartz Commercial |
$1,102.56
|
| Rate for Payer: Quartz Medicare Advantage |
$3,767.97
|
| Rate for Payer: The Alliance Commercial |
$15,071.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,767.97
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$932.93
|
| Rate for Payer: Wellcare Medicare |
$3,767.97
|
| Rate for Payer: WPS Commercial |
$1,256.36
|
|
|
Inj Wrist Arthrography
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$391.88 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$479.86
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
Inj Wrist Arthrography
|
Professional
|
Both
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$60.12 |
| Max. Negotiated Rate |
$759.77 |
| Rate for Payer: Aetna Commercial |
$759.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Aetna Managed Medicare |
$60.12
|
| Rate for Payer: Anthem Medicare Advantage |
$60.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.12
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$759.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.12
|
| Rate for Payer: Health EOS Commercial |
$727.78
|
| Rate for Payer: HFN Commercial |
$759.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$259.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.12
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: NAPHCARE Commercial |
$90.18
|
| Rate for Payer: Preferred Network Access Commercial |
$759.77
|
| Rate for Payer: Quartz Beloit One Network |
$351.89
|
| Rate for Payer: Quartz Commercial |
$455.86
|
| Rate for Payer: Quartz Medicare Advantage |
$60.12
|
| Rate for Payer: The Alliance Commercial |
$255.52
|
| Rate for Payer: United Healthcare Medicaid |
$63.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.12
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$270.55
|
|
|
Inj Wrist Arthrography
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
CPT 25246
|
| Hospital Charge Code |
3072741
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Aetna Managed Medicare |
$223.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$519.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$399.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$383.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$599.82
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: NAPHCARE Commercial |
$479.86
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: Quartz Medicare Advantage |
$479.86
|
| Rate for Payer: The Alliance Commercial |
$240.49
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
INJX ANTERIOR CHAMBER EYE MEDICATION SPX 66030
|
Professional
|
Both
|
$683.00
|
|
|
Service Code
|
CPT 66030
|
| Hospital Charge Code |
5907635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$674.80 |
| Rate for Payer: Aetna Commercial |
$674.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.88
|
| Rate for Payer: Aetna Managed Medicare |
$96.99
|
| Rate for Payer: Anthem Medicare Advantage |
$96.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$96.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$96.99
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cash Price |
$204.90
|
| Rate for Payer: Cigna Commercial |
$674.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.99
|
| Rate for Payer: Health EOS Commercial |
$646.39
|
| Rate for Payer: HFN Commercial |
$674.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$387.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$387.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$96.99
|
| Rate for Payer: Multiplan Commercial |
$568.26
|
| Rate for Payer: NAPHCARE Commercial |
$145.49
|
| Rate for Payer: Preferred Network Access Commercial |
$674.80
|
| Rate for Payer: Quartz Beloit One Network |
$312.54
|
| Rate for Payer: Quartz Commercial |
$404.88
|
| Rate for Payer: Quartz Medicare Advantage |
$96.99
|
| Rate for Payer: The Alliance Commercial |
$412.21
|
| Rate for Payer: United Healthcare Medicaid |
$62.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$96.99
|
| Rate for Payer: WEA Trust Commercial |
$390.68
|
| Rate for Payer: WPS Commercial |
$436.46
|
|
|
Inner cannula changed - Tracheostomy Tube Activity
|
Facility
|
OP
|
$306.00
|
|
| Hospital Charge Code |
3000325
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$89.11 |
| Max. Negotiated Rate |
$313.04 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.69
|
| Rate for Payer: Aetna Managed Medicare |
$89.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$206.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$159.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$152.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.67
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$292.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.09
|
| Rate for Payer: Health EOS Commercial |
$283.23
|
| Rate for Payer: HFN Commercial |
$292.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$238.68
|
| Rate for Payer: Multiplan Commercial |
$254.59
|
| Rate for Payer: NAPHCARE Commercial |
$190.94
|
| Rate for Payer: Preferred Network Access Commercial |
$292.78
|
| Rate for Payer: Quartz Beloit One Network |
$155.94
|
| Rate for Payer: Quartz Commercial |
$206.86
|
| Rate for Payer: Quartz Medicare Advantage |
$190.94
|
| Rate for Payer: The Alliance Commercial |
$159.12
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$175.03
|
| Rate for Payer: WPS Commercial |
$235.71
|
|
|
Inner cannula changed - Tracheostomy Tube Activity
|
Facility
|
IP
|
$306.00
|
|
| Hospital Charge Code |
3000325
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$155.94 |
| Max. Negotiated Rate |
$292.78 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.67
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$292.78
|
| Rate for Payer: Health EOS Commercial |
$283.23
|
| Rate for Payer: HFN Commercial |
$292.78
|
| Rate for Payer: Multiplan Commercial |
$254.59
|
| Rate for Payer: Preferred Network Access Commercial |
$292.78
|
| Rate for Payer: Quartz Beloit One Network |
$155.94
|
| Rate for Payer: Quartz Commercial |
$190.94
|
| Rate for Payer: WEA Trust Commercial |
$175.03
|
| Rate for Payer: WPS Commercial |
$235.71
|
|
|
INNER CANNULA SHILEY SZ4 4IC65
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS A4623
|
| Hospital Charge Code |
5641669
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
INNER CANNULA SHILEY SZ4 4IC65
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS A4623
|
| Hospital Charge Code |
5641669
|
|
Hospital Revenue Code
|
272
|
| 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: 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 |
$38.85
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
INNER CANNULA TRACH 6 FEN 6DICFEN
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
5415186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
INNER CANNULA TRACH 6 FEN 6DICFEN
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
5415186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.76 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$126.36
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
INNER CANNULA TRACH 6 NON-FEN 6DIC
|
Facility
|
OP
|
$236.00
|
|
| Hospital Charge Code |
5415183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.72 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Aetna Managed Medicare |
$68.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.35
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.08
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: NAPHCARE Commercial |
$147.26
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$159.54
|
| Rate for Payer: Quartz Medicare Advantage |
$147.26
|
| Rate for Payer: The Alliance Commercial |
$122.72
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
INNER CANNULA TRACH 6 NON-FEN 6DIC
|
Facility
|
IP
|
$236.00
|
|
| Hospital Charge Code |
5415183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$147.26
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
INNER CANNULA TRACH 8 FEN 8DICFEN
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
5415187
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.76 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.43
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$126.36
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
INNER CANNULA TRACH 8 FEN 8DICFEN
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
5415187
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
INNER CANNULA TRACH 8 NON-FEN 8DIC
|
Facility
|
OP
|
$236.00
|
|
| Hospital Charge Code |
5415185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.72 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Aetna Managed Medicare |
$68.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.35
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.08
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: NAPHCARE Commercial |
$147.26
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$159.54
|
| Rate for Payer: Quartz Medicare Advantage |
$147.26
|
| Rate for Payer: The Alliance Commercial |
$122.72
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
INNER CANNULA TRACH 8 NON-FEN 8DIC
|
Facility
|
IP
|
$236.00
|
|
| Hospital Charge Code |
5415185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$147.26
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
Inpatient Hemodialysis
|
Facility
|
OP
|
$1,950.00
|
|
| Hospital Charge Code |
3005578
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$567.84 |
| Max. Negotiated Rate |
$1,865.76 |
| Rate for Payer: Aetna Commercial |
$1,825.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,744.08
|
| Rate for Payer: Aetna Managed Medicare |
$567.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,318.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,014.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$973.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,074.84
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$1,865.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,134.90
|
| Rate for Payer: Health EOS Commercial |
$1,804.92
|
| Rate for Payer: HFN Commercial |
$1,865.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,521.00
|
| Rate for Payer: Multiplan Commercial |
$1,622.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,216.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,865.76
|
| Rate for Payer: Quartz Beloit One Network |
$993.72
|
| Rate for Payer: Quartz Commercial |
$1,318.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,216.80
|
| Rate for Payer: The Alliance Commercial |
$1,014.00
|
| Rate for Payer: WEA Trust Commercial |
$1,115.40
|
| Rate for Payer: WPS Commercial |
$1,502.09
|
|
