|
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 |
$60.27 |
| Max. Negotiated Rate |
$648.85 |
| Rate for Payer: Aetna Commercial |
$648.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$587.38
|
| 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 |
$648.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.80
|
| Rate for Payer: Health EOS Commercial |
$621.53
|
| Rate for Payer: HFN Commercial |
$648.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$372.63
|
| Rate for Payer: Multiplan Commercial |
$546.40
|
| Rate for Payer: Preferred Network Access Commercial |
$648.85
|
| Rate for Payer: Quartz Beloit One Network |
$300.52
|
| Rate for Payer: Quartz Commercial |
$389.31
|
| Rate for Payer: The Alliance Commercial |
$341.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.27
|
| Rate for Payer: WEA Trust Commercial |
$375.65
|
| Rate for Payer: WPS Commercial |
$505.90
|
|
|
Inner cannula changed - Tracheostomy Tube Activity
|
Facility
|
OP
|
$306.00
|
|
| Hospital Charge Code |
3000325
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.68 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$275.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$263.16
|
| Rate for Payer: Aetna Managed Medicare |
$85.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$198.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$153.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$146.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.18
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$281.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.24
|
| Rate for Payer: Health EOS Commercial |
$272.34
|
| Rate for Payer: HFN Commercial |
$281.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$229.50
|
| Rate for Payer: Multiplan Commercial |
$244.80
|
| Rate for Payer: NAPHCARE Commercial |
$183.60
|
| Rate for Payer: Preferred Network Access Commercial |
$281.52
|
| Rate for Payer: Quartz Beloit One Network |
$149.94
|
| Rate for Payer: Quartz Commercial |
$198.90
|
| Rate for Payer: Quartz Medicare Advantage |
$183.60
|
| Rate for Payer: The Alliance Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$168.30
|
| Rate for Payer: WPS Commercial |
$226.65
|
|
|
Inner cannula changed - Tracheostomy Tube Activity
|
Facility
|
IP
|
$306.00
|
|
| Hospital Charge Code |
3000325
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$149.94 |
| Max. Negotiated Rate |
$281.52 |
| Rate for Payer: Aetna Commercial |
$275.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$263.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.18
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cigna Commercial |
$281.52
|
| Rate for Payer: Health EOS Commercial |
$272.34
|
| Rate for Payer: HFN Commercial |
$281.52
|
| Rate for Payer: Multiplan Commercial |
$244.80
|
| Rate for Payer: NAPHCARE Commercial |
$183.60
|
| Rate for Payer: Preferred Network Access Commercial |
$281.52
|
| Rate for Payer: Quartz Beloit One Network |
$149.94
|
| Rate for Payer: Quartz Commercial |
$183.60
|
| Rate for Payer: WEA Trust Commercial |
$168.30
|
| Rate for Payer: WPS Commercial |
$226.65
|
|
|
INNER CANNULA SHILEY SZ4 4IC65
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS A4623
|
| Hospital Charge Code |
5641669
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
INNER CANNULA SHILEY SZ4 4IC65
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS A4623
|
| Hospital Charge Code |
5641669
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
INNER CANNULA TRACH 6 FEN 6DICFEN
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
5415186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.04 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$157.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
INNER CANNULA TRACH 6 FEN 6DICFEN
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
5415186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
INNER CANNULA TRACH 6 NON-FEN 6DIC
|
Facility
|
OP
|
$236.00
|
|
| Hospital Charge Code |
5415183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$944.00 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Aetna Managed Medicare |
$66.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$113.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.07
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.00
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$153.40
|
| Rate for Payer: Quartz Medicare Advantage |
$141.60
|
| Rate for Payer: The Alliance Commercial |
$944.00
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
INNER CANNULA TRACH 6 NON-FEN 6DIC
|
Facility
|
IP
|
$236.00
|
|
| Hospital Charge Code |
5415183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$217.12 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$141.60
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
INNER CANNULA TRACH 8 FEN 8DICFEN
|
Facility
|
IP
|
$243.00
|
|
| Hospital Charge Code |
5415187
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
INNER CANNULA TRACH 8 FEN 8DICFEN
|
Facility
|
OP
|
$243.00
|
|
| Hospital Charge Code |
5415187
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.04 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$157.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.98
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
INNER CANNULA TRACH 8 NON-FEN 8DIC
|
Facility
|
IP
|
$236.00
|
|
| Hospital Charge Code |
5415185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$217.12 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$141.60
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
INNER CANNULA TRACH 8 NON-FEN 8DIC
|
Facility
|
OP
|
$236.00
|
|
| Hospital Charge Code |
5415185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$944.00 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Aetna Managed Medicare |
$66.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$113.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.07
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.00
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$153.40
|
| Rate for Payer: Quartz Medicare Advantage |
$141.60
|
| Rate for Payer: The Alliance Commercial |
$944.00
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
Inpatient Hemodialysis
|
Facility
|
IP
|
$1,950.00
|
|
| Hospital Charge Code |
3005578
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$955.50 |
| Max. Negotiated Rate |
$1,794.00 |
| Rate for Payer: Aetna Commercial |
$1,755.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,677.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,033.50
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$1,794.00
|
| Rate for Payer: Health EOS Commercial |
$1,735.50
|
| Rate for Payer: HFN Commercial |
$1,794.00
|
| Rate for Payer: Multiplan Commercial |
$1,560.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,170.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,794.00
|
| Rate for Payer: Quartz Beloit One Network |
$955.50
|
| Rate for Payer: Quartz Commercial |
$1,170.00
|
| Rate for Payer: WEA Trust Commercial |
$1,072.50
|
| Rate for Payer: WPS Commercial |
$1,444.36
|
|
|
Inpatient Hemodialysis
|
Facility
|
OP
|
$1,950.00
|
|
| Hospital Charge Code |
3005578
|
|
Hospital Revenue Code
|
801
|
| Min. Negotiated Rate |
$546.00 |
| Max. Negotiated Rate |
$7,800.00 |
| Rate for Payer: Aetna Commercial |
$1,755.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,677.00
|
| Rate for Payer: Aetna Managed Medicare |
$546.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,267.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$975.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$936.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,033.50
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$1,794.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,091.22
|
| Rate for Payer: Health EOS Commercial |
$1,735.50
|
| Rate for Payer: HFN Commercial |
$1,794.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,462.50
|
| Rate for Payer: Multiplan Commercial |
$1,560.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,170.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,794.00
|
| Rate for Payer: Quartz Beloit One Network |
$955.50
|
| Rate for Payer: Quartz Commercial |
$1,267.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,170.00
|
| Rate for Payer: The Alliance Commercial |
$7,800.00
|
| Rate for Payer: WEA Trust Commercial |
$1,072.50
|
| Rate for Payer: WPS Commercial |
$1,444.36
|
|
|
Inpatient Lumbar Puncture
|
Facility
|
IP
|
$628.00
|
|
|
Service Code
|
CPT 62328
|
| Hospital Charge Code |
2952003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$307.72 |
| Max. Negotiated Rate |
$577.76 |
| Rate for Payer: Aetna Commercial |
$565.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$540.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$332.84
|
| Rate for Payer: Cash Price |
$188.40
|
| Rate for Payer: Cigna Commercial |
$577.76
|
| Rate for Payer: Health EOS Commercial |
$558.92
|
| Rate for Payer: HFN Commercial |
$577.76
|
| Rate for Payer: Multiplan Commercial |
$502.40
|
| Rate for Payer: NAPHCARE Commercial |
$376.80
|
| Rate for Payer: Preferred Network Access Commercial |
$577.76
|
| Rate for Payer: Quartz Beloit One Network |
$307.72
|
| Rate for Payer: Quartz Commercial |
$376.80
|
| Rate for Payer: WEA Trust Commercial |
$345.40
|
| Rate for Payer: WPS Commercial |
$465.16
|
|
|
Inpatient Lumbar Puncture
|
Facility
|
OP
|
$628.00
|
|
|
Service Code
|
CPT 62328
|
| Hospital Charge Code |
2952003
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$301.44 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$565.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$540.08
|
| Rate for Payer: Aetna Managed Medicare |
$683.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$408.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$314.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$301.44
|
| Rate for Payer: Anthem Medicare Advantage |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$332.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$683.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$683.53
|
| Rate for Payer: Cash Price |
$188.40
|
| Rate for Payer: Cash Price |
$188.40
|
| Rate for Payer: Cigna Commercial |
$577.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$683.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$683.53
|
| Rate for Payer: Health EOS Commercial |
$558.92
|
| Rate for Payer: HFN Commercial |
$577.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,542.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$683.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$683.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$683.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$683.53
|
| Rate for Payer: Multiplan Commercial |
$502.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.30
|
| Rate for Payer: Preferred Network Access Commercial |
$577.76
|
| Rate for Payer: Quartz Beloit One Network |
$307.72
|
| Rate for Payer: Quartz Commercial |
$408.20
|
| Rate for Payer: Quartz Medicare Advantage |
$683.53
|
| Rate for Payer: The Alliance Commercial |
$2,734.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$683.53
|
| Rate for Payer: United Healthcare PPO |
$471.00
|
| Rate for Payer: WEA Trust Commercial |
$345.40
|
| Rate for Payer: Wellcare Medicare |
$683.53
|
| Rate for Payer: WPS Commercial |
$465.16
|
|
|
Inpt Consult Brief
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
CPT 99252
|
| Hospital Charge Code |
3040423
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$134.26 |
| Max. Negotiated Rate |
$252.08 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$164.40
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
Inpt Consult Brief
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
CPT 99252
|
| Hospital Charge Code |
3040423
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$76.72 |
| Max. Negotiated Rate |
$1,096.00 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Aetna Managed Medicare |
$76.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.33
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$205.50
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$178.10
|
| Rate for Payer: Quartz Medicare Advantage |
$164.40
|
| Rate for Payer: The Alliance Commercial |
$1,096.00
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
Inpt Consult Extended
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
CPT 99254
|
| Hospital Charge Code |
3040425
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$118.44 |
| Max. Negotiated Rate |
$1,692.00 |
| Rate for Payer: Aetna Commercial |
$380.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.78
|
| Rate for Payer: Aetna Managed Medicare |
$118.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$274.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$203.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.19
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna Commercial |
$389.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.71
|
| Rate for Payer: Health EOS Commercial |
$376.47
|
| Rate for Payer: HFN Commercial |
$389.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$317.25
|
| Rate for Payer: Multiplan Commercial |
$338.40
|
| Rate for Payer: NAPHCARE Commercial |
$253.80
|
| Rate for Payer: Preferred Network Access Commercial |
$389.16
|
| Rate for Payer: Quartz Beloit One Network |
$207.27
|
| Rate for Payer: Quartz Commercial |
$274.95
|
| Rate for Payer: Quartz Medicare Advantage |
$253.80
|
| Rate for Payer: The Alliance Commercial |
$1,692.00
|
| Rate for Payer: WEA Trust Commercial |
$232.65
|
| Rate for Payer: WPS Commercial |
$313.32
|
|
|
Inpt Consult Extended
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
CPT 99254
|
| Hospital Charge Code |
3040425
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.27 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna Commercial |
$380.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.19
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna Commercial |
$389.16
|
| Rate for Payer: Health EOS Commercial |
$376.47
|
| Rate for Payer: HFN Commercial |
$389.16
|
| Rate for Payer: Multiplan Commercial |
$338.40
|
| Rate for Payer: NAPHCARE Commercial |
$253.80
|
| Rate for Payer: Preferred Network Access Commercial |
$389.16
|
| Rate for Payer: Quartz Beloit One Network |
$207.27
|
| Rate for Payer: Quartz Commercial |
$253.80
|
| Rate for Payer: WEA Trust Commercial |
$232.65
|
| Rate for Payer: WPS Commercial |
$313.32
|
|
|
Inpt Consult Routine
|
Facility
|
OP
|
$348.00
|
|
|
Service Code
|
CPT 99253
|
| Hospital Charge Code |
3040424
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.44 |
| Max. Negotiated Rate |
$1,392.00 |
| Rate for Payer: Aetna Commercial |
$313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$299.28
|
| Rate for Payer: Aetna Managed Medicare |
$97.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$226.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$174.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$167.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.44
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$320.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.74
|
| Rate for Payer: Health EOS Commercial |
$309.72
|
| Rate for Payer: HFN Commercial |
$320.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.00
|
| Rate for Payer: Multiplan Commercial |
$278.40
|
| Rate for Payer: NAPHCARE Commercial |
$208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$320.16
|
| Rate for Payer: Quartz Beloit One Network |
$170.52
|
| Rate for Payer: Quartz Commercial |
$226.20
|
| Rate for Payer: Quartz Medicare Advantage |
$208.80
|
| Rate for Payer: The Alliance Commercial |
$1,392.00
|
| Rate for Payer: WEA Trust Commercial |
$191.40
|
| Rate for Payer: WPS Commercial |
$257.76
|
|
|
Inpt Consult Routine
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
CPT 99253
|
| Hospital Charge Code |
3040424
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.52 |
| Max. Negotiated Rate |
$320.16 |
| Rate for Payer: Aetna Commercial |
$313.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$299.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$184.44
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$320.16
|
| Rate for Payer: Health EOS Commercial |
$309.72
|
| Rate for Payer: HFN Commercial |
$320.16
|
| Rate for Payer: Multiplan Commercial |
$278.40
|
| Rate for Payer: NAPHCARE Commercial |
$208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$320.16
|
| Rate for Payer: Quartz Beloit One Network |
$170.52
|
| Rate for Payer: Quartz Commercial |
$208.80
|
| Rate for Payer: WEA Trust Commercial |
$191.40
|
| Rate for Payer: WPS Commercial |
$257.76
|
|
|
INSERT AND REMOVE BONE PIN 20650
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 20650
|
| Hospital Charge Code |
3013707
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$99.85 |
| Max. Negotiated Rate |
$529.18 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$99.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$304.80
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: HFN Commercial |
$482.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$529.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$529.18
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: The Alliance Commercial |
$254.00
|
| Rate for Payer: United Healthcare Medicaid |
$99.85
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$376.28
|
|
|
INSERT AS TIBIAL BEARING DCM ARCOM VANGUARD 12MM X 71MM 189062
|
Facility
|
IP
|
$5,053.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6170218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,475.97 |
| Max. Negotiated Rate |
$4,648.76 |
| Rate for Payer: Aetna Commercial |
$4,547.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,345.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,678.09
|
| Rate for Payer: Cash Price |
$1,515.90
|
| Rate for Payer: Cigna Commercial |
$4,648.76
|
| Rate for Payer: Health EOS Commercial |
$4,497.17
|
| Rate for Payer: HFN Commercial |
$4,648.76
|
| Rate for Payer: Multiplan Commercial |
$4,042.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,031.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,648.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,475.97
|
| Rate for Payer: Quartz Commercial |
$3,031.80
|
| Rate for Payer: WEA Trust Commercial |
$2,779.15
|
| Rate for Payer: WPS Commercial |
$3,742.76
|
|
