|
Inj Admin Hormonal Antineoplastic 96402 - Admin Chemo SubQ/IM Hormonal Antineoplastic
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 96402 59
|
| Hospital Charge Code |
3165610
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Inj Admin Hormonal Antineoplastic 96402 - Admin Chemo SubQ/IM Hormonal Antineoplastic
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 96402 59
|
| Hospital Charge Code |
3165610
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$103.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.68
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$222.14
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$222.14
|
| Rate for Payer: The Alliance Commercial |
$185.12
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Inj Admin Intravitreal 67028 - Admin Intravitreal Injection Charge
|
Professional
|
Both
|
$698.00
|
|
|
Service Code
|
CPT 67028
|
| Hospital Charge Code |
3023771
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$689.62 |
| Rate for Payer: Aetna Commercial |
$689.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$624.29
|
| Rate for Payer: Aetna Managed Medicare |
$74.77
|
| Rate for Payer: Anthem Medicare Advantage |
$74.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.77
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$689.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.77
|
| Rate for Payer: Health EOS Commercial |
$660.59
|
| Rate for Payer: HFN Commercial |
$689.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$322.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.77
|
| Rate for Payer: Multiplan Commercial |
$580.74
|
| Rate for Payer: NAPHCARE Commercial |
$112.15
|
| Rate for Payer: Preferred Network Access Commercial |
$689.62
|
| Rate for Payer: Quartz Beloit One Network |
$319.40
|
| Rate for Payer: Quartz Commercial |
$413.77
|
| Rate for Payer: Quartz Medicare Advantage |
$74.77
|
| Rate for Payer: The Alliance Commercial |
$317.75
|
| Rate for Payer: United Healthcare Medicaid |
$177.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.77
|
| Rate for Payer: WEA Trust Commercial |
$399.26
|
| Rate for Payer: WPS Commercial |
$336.45
|
|
|
Inj Admin Non-hormonal Antineoplastic 96401 - Admin Chemo SubQ/IM Non-hormonal Antineoplastic
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3437512
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$55.49 |
| Max. Negotiated Rate |
$435.71 |
| Rate for Payer: Aetna Commercial |
$435.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.43
|
| Rate for Payer: Aetna Managed Medicare |
$70.95
|
| Rate for Payer: Anthem Medicare Advantage |
$70.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$70.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$70.95
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$435.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.95
|
| Rate for Payer: Health EOS Commercial |
$417.36
|
| Rate for Payer: HFN Commercial |
$435.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$282.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$282.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$70.95
|
| Rate for Payer: Multiplan Commercial |
$366.91
|
| Rate for Payer: NAPHCARE Commercial |
$106.42
|
| Rate for Payer: Preferred Network Access Commercial |
$435.71
|
| Rate for Payer: Quartz Beloit One Network |
$201.80
|
| Rate for Payer: Quartz Commercial |
$261.42
|
| Rate for Payer: Quartz Medicare Advantage |
$70.95
|
| Rate for Payer: The Alliance Commercial |
$177.37
|
| Rate for Payer: United Healthcare Medicaid |
$55.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.95
|
| Rate for Payer: WEA Trust Commercial |
$252.25
|
| Rate for Payer: WPS Commercial |
$283.80
|
|
|
Inj Admin Non-hormonal Antineoplastic 96401 - Admin Chemo SubQ/IM Non-hormonal Antineoplastic
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3437512
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$421.95 |
| Rate for Payer: Aetna Commercial |
$412.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.43
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$298.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$229.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220.15
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$421.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$256.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$408.19
|
| Rate for Payer: HFN Commercial |
$421.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$366.91
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$421.95
|
| Rate for Payer: Quartz Beloit One Network |
$224.73
|
| Rate for Payer: Quartz Commercial |
$298.12
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$343.98
|
| Rate for Payer: WEA Trust Commercial |
$252.25
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$339.70
|
|
|
Inj Admin Non-hormonal Antineoplastic 96401 - Admin Chemo SubQ/IM Non-hormonal Antineoplastic
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3437512
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$224.73 |
| Max. Negotiated Rate |
$421.95 |
| Rate for Payer: Aetna Commercial |
$412.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.08
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$421.95
|
| Rate for Payer: Health EOS Commercial |
$408.19
|
| Rate for Payer: HFN Commercial |
$421.95
|
| Rate for Payer: Multiplan Commercial |
$366.91
|
| Rate for Payer: Preferred Network Access Commercial |
$421.95
|
| Rate for Payer: Quartz Beloit One Network |
$224.73
|
| Rate for Payer: Quartz Commercial |
$275.18
|
| Rate for Payer: WEA Trust Commercial |
$252.25
|
| Rate for Payer: WPS Commercial |
$339.70
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$220.32 |
| Rate for Payer: Aetna Commercial |
$220.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$15.33
|
| Rate for Payer: Anthem Medicare Advantage |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.33
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$220.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.33
|
| Rate for Payer: Health EOS Commercial |
$211.05
|
| Rate for Payer: HFN Commercial |
$220.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$22.99
|
| Rate for Payer: Preferred Network Access Commercial |
$220.32
|
| Rate for Payer: Quartz Beloit One Network |
$102.04
|
| Rate for Payer: Quartz Commercial |
$132.19
|
| Rate for Payer: Quartz Medicare Advantage |
$15.33
|
| Rate for Payer: The Alliance Commercial |
$38.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.33
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$61.32
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$2.11
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.84
|
| Rate for Payer: Health EOS Commercial |
$4.73
|
| Rate for Payer: HFN Commercial |
$4.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.94
|
| Rate for Payer: Quartz Beloit One Network |
$2.29
|
| Rate for Payer: Quartz Commercial |
$2.96
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$2.11
|
|
|
Inj Ankle Arthrograpy
|
Facility
|
OP
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$167.23 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Aetna Managed Medicare |
$262.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$609.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$469.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$450.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: NAPHCARE Commercial |
$562.85
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$609.75
|
| Rate for Payer: Quartz Medicare Advantage |
$562.85
|
| Rate for Payer: The Alliance Commercial |
$167.23
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
Inj Ankle Arthrograpy
|
Professional
|
Both
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$891.18 |
| Rate for Payer: Aetna Commercial |
$891.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Aetna Managed Medicare |
$41.81
|
| Rate for Payer: Anthem Medicare Advantage |
$41.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.81
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$891.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.81
|
| Rate for Payer: Health EOS Commercial |
$853.65
|
| Rate for Payer: HFN Commercial |
$891.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.81
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: NAPHCARE Commercial |
$62.71
|
| Rate for Payer: Preferred Network Access Commercial |
$891.18
|
| Rate for Payer: Quartz Beloit One Network |
$412.76
|
| Rate for Payer: Quartz Commercial |
$534.71
|
| Rate for Payer: Quartz Medicare Advantage |
$41.81
|
| Rate for Payer: The Alliance Commercial |
$177.68
|
| Rate for Payer: United Healthcare Medicaid |
$46.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
Inj Ankle Arthrograpy
|
Facility
|
IP
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$459.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$562.85
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
Inj, Bupivacaine Liposome C9290
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Inj, Bupivacaine Liposome C9290
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Inj, Bupivacaine Liposome C9290
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.37
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Professional
|
Both
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.19
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: The Alliance Commercial |
$30.16
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Facility
|
OP
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.89 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$16.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.24
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$36.19
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$36.19
|
| Rate for Payer: The Alliance Commercial |
$30.16
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$268.74 |
| Rate for Payer: Aetna Commercial |
$268.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$19.12
|
| Rate for Payer: Anthem Medicare Advantage |
$19.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.12
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$268.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.74
|
| Rate for Payer: Health EOS Commercial |
$257.42
|
| Rate for Payer: HFN Commercial |
$268.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.12
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$28.67
|
| Rate for Payer: Preferred Network Access Commercial |
$268.74
|
| Rate for Payer: Quartz Beloit One Network |
$124.47
|
| Rate for Payer: Quartz Commercial |
$161.24
|
| Rate for Payer: Quartz Medicare Advantage |
$19.12
|
| Rate for Payer: The Alliance Commercial |
$52.57
|
| Rate for Payer: United Healthcare Medicaid |
$21.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.12
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$74.34
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.34 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$79.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$183.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$141.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$135.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.34
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$212.16
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$169.73
|
| Rate for Payer: The Alliance Commercial |
$76.46
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$74.34
|
|
|
Inj Cystogram
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$877.34 |
| Rate for Payer: Aetna Commercial |
$877.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$877.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$840.40
|
| Rate for Payer: HFN Commercial |
$877.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$153.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$877.34
|
| Rate for Payer: Quartz Beloit One Network |
$406.35
|
| Rate for Payer: Quartz Commercial |
$526.41
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$155.10
|
| Rate for Payer: United Healthcare Medicaid |
$25.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$164.22
|
|
