|
Alveolar Lavage - Bronchoscopy Charge
|
Facility
|
IP
|
$4,066.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
2990183
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,072.03 |
| Max. Negotiated Rate |
$3,890.35 |
| Rate for Payer: Aetna Commercial |
$3,805.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,636.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,241.18
|
| Rate for Payer: Cash Price |
$1,219.80
|
| Rate for Payer: Cigna Commercial |
$3,890.35
|
| Rate for Payer: Health EOS Commercial |
$3,763.49
|
| Rate for Payer: HFN Commercial |
$3,890.35
|
| Rate for Payer: Multiplan Commercial |
$3,382.91
|
| Rate for Payer: Preferred Network Access Commercial |
$3,890.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,072.03
|
| Rate for Payer: Quartz Commercial |
$2,537.18
|
| Rate for Payer: WEA Trust Commercial |
$2,325.75
|
| Rate for Payer: WPS Commercial |
$3,132.04
|
|
|
Alveolar Lavage - Bronchoscopy Charge
|
Facility
|
OP
|
$4,066.00
|
|
|
Service Code
|
CPT 31624
|
| Hospital Charge Code |
2990183
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,873.14 |
| Max. Negotiated Rate |
$6,968.10 |
| Rate for Payer: Aetna Commercial |
$3,805.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,636.63
|
| Rate for Payer: Aetna Managed Medicare |
$1,873.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,873.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,241.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,873.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,873.14
|
| Rate for Payer: Cash Price |
$1,219.80
|
| Rate for Payer: Cash Price |
$1,219.80
|
| Rate for Payer: Cash Price |
$1,219.80
|
| Rate for Payer: Cigna Commercial |
$3,890.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,873.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,873.14
|
| Rate for Payer: Health EOS Commercial |
$3,763.49
|
| Rate for Payer: HFN Commercial |
$3,890.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,968.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,873.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,873.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,873.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,873.14
|
| Rate for Payer: Multiplan Commercial |
$3,382.91
|
| Rate for Payer: NAPHCARE Commercial |
$2,809.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,890.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,072.03
|
| Rate for Payer: Quartz Commercial |
$2,748.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,873.14
|
| Rate for Payer: The Alliance Commercial |
$3,184.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,873.14
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: WEA Trust Commercial |
$2,325.75
|
| Rate for Payer: Wellcare Medicare |
$1,873.14
|
| Rate for Payer: WPS Commercial |
$3,132.04
|
|
|
ALVEOLECTOMY & ALVEOLOPLASTY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959784
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
ALVEOLECTOMY & ALVEOLOPLASTY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959784
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
AMBU BAG RESUSCITATOR INFANT-2YR. AMBU 540216030
|
Facility
|
OP
|
$409.00
|
|
| Hospital Charge Code |
2963016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$391.33 |
| Rate for Payer: Aetna Commercial |
$382.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.81
|
| Rate for Payer: Aetna Managed Medicare |
$119.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$276.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$204.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.44
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$391.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.04
|
| Rate for Payer: Health EOS Commercial |
$378.57
|
| Rate for Payer: HFN Commercial |
$391.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$319.02
|
| Rate for Payer: Multiplan Commercial |
$340.29
|
| Rate for Payer: NAPHCARE Commercial |
$255.22
|
| Rate for Payer: Preferred Network Access Commercial |
$391.33
|
| Rate for Payer: Quartz Beloit One Network |
$208.43
|
| Rate for Payer: Quartz Commercial |
$276.48
|
| Rate for Payer: Quartz Medicare Advantage |
$255.22
|
| Rate for Payer: The Alliance Commercial |
$212.68
|
| Rate for Payer: WEA Trust Commercial |
$233.95
|
| Rate for Payer: WPS Commercial |
$315.05
|
|
|
AMBU BAG RESUSCITATOR INFANT-2YR. AMBU 540216030
|
Facility
|
IP
|
$409.00
|
|
| Hospital Charge Code |
2963016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$208.43 |
| Max. Negotiated Rate |
$391.33 |
| Rate for Payer: Aetna Commercial |
$382.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$365.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$225.44
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$391.33
|
| Rate for Payer: Health EOS Commercial |
$378.57
|
| Rate for Payer: HFN Commercial |
$391.33
|
| Rate for Payer: Multiplan Commercial |
$340.29
|
| Rate for Payer: Preferred Network Access Commercial |
$391.33
|
| Rate for Payer: Quartz Beloit One Network |
$208.43
|
| Rate for Payer: Quartz Commercial |
$255.22
|
| Rate for Payer: WEA Trust Commercial |
$233.95
|
| Rate for Payer: WPS Commercial |
$315.05
|
|
|
AMBULATORY PATIENT MONITORING AND RELATED ASSESSMENTS
|
Facility
|
OP
|
$132.34
|
|
|
Service Code
|
EAPG 00418
|
| Min. Negotiated Rate |
$127.25 |
| Max. Negotiated Rate |
$132.34 |
| Rate for Payer: Anthem Medicaid |
$127.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$127.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.25
|
| Rate for Payer: Dean Health Medicaid |
$127.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$127.25
|
| Rate for Payer: Managed Health Services Medicaid |
$132.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$127.25
|
| Rate for Payer: United Healthcare Medicaid |
$127.25
|
|
|
Ambulatory Recovery 4/Hours
|
Facility
|
OP
|
$309.00
|
|
| Hospital Charge Code |
3052553
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$89.98 |
| Max. Negotiated Rate |
$295.65 |
| Rate for Payer: Aetna Commercial |
$289.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.37
|
| Rate for Payer: Aetna Managed Medicare |
$89.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.32
|
| Rate for Payer: Cash Price |
$92.70
|
| Rate for Payer: Cigna Commercial |
$295.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.84
|
| Rate for Payer: Health EOS Commercial |
$286.01
|
| Rate for Payer: HFN Commercial |
$295.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.02
|
| Rate for Payer: Multiplan Commercial |
$257.09
|
| Rate for Payer: NAPHCARE Commercial |
$192.82
|
| Rate for Payer: Preferred Network Access Commercial |
$295.65
|
| Rate for Payer: Quartz Beloit One Network |
$157.47
|
| Rate for Payer: Quartz Commercial |
$208.88
|
| Rate for Payer: Quartz Medicare Advantage |
$192.82
|
| Rate for Payer: The Alliance Commercial |
$160.68
|
| Rate for Payer: WEA Trust Commercial |
$176.75
|
| Rate for Payer: WPS Commercial |
$238.02
|
|
|
Ambulatory Recovery 4/Hours
|
Facility
|
IP
|
$309.00
|
|
| Hospital Charge Code |
3052553
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$157.47 |
| Max. Negotiated Rate |
$295.65 |
| Rate for Payer: Aetna Commercial |
$289.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.32
|
| Rate for Payer: Cash Price |
$92.70
|
| Rate for Payer: Cigna Commercial |
$295.65
|
| Rate for Payer: Health EOS Commercial |
$286.01
|
| Rate for Payer: HFN Commercial |
$295.65
|
| Rate for Payer: Multiplan Commercial |
$257.09
|
| Rate for Payer: Preferred Network Access Commercial |
$295.65
|
| Rate for Payer: Quartz Beloit One Network |
$157.47
|
| Rate for Payer: Quartz Commercial |
$192.82
|
| Rate for Payer: WEA Trust Commercial |
$176.75
|
| Rate for Payer: WPS Commercial |
$238.02
|
|
|
Ambulatory Recovery Charge
|
Facility
|
IP
|
$1,317.00
|
|
| Hospital Charge Code |
3243537
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$671.14 |
| Max. Negotiated Rate |
$1,260.11 |
| Rate for Payer: Aetna Commercial |
$1,232.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,177.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$725.93
|
| Rate for Payer: Cash Price |
$395.10
|
| Rate for Payer: Cigna Commercial |
$1,260.11
|
| Rate for Payer: Health EOS Commercial |
$1,219.02
|
| Rate for Payer: HFN Commercial |
$1,260.11
|
| Rate for Payer: Multiplan Commercial |
$1,095.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,260.11
|
| Rate for Payer: Quartz Beloit One Network |
$671.14
|
| Rate for Payer: Quartz Commercial |
$821.81
|
| Rate for Payer: WEA Trust Commercial |
$753.32
|
| Rate for Payer: WPS Commercial |
$1,014.49
|
|
|
Ambulatory Recovery Charge
|
Facility
|
OP
|
$1,317.00
|
|
| Hospital Charge Code |
3243537
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$383.51 |
| Max. Negotiated Rate |
$1,260.11 |
| Rate for Payer: Aetna Commercial |
$1,232.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,177.92
|
| Rate for Payer: Aetna Managed Medicare |
$383.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$890.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$684.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$657.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$725.93
|
| Rate for Payer: Cash Price |
$395.10
|
| Rate for Payer: Cigna Commercial |
$1,260.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$766.49
|
| Rate for Payer: Health EOS Commercial |
$1,219.02
|
| Rate for Payer: HFN Commercial |
$1,260.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,027.26
|
| Rate for Payer: Multiplan Commercial |
$1,095.74
|
| Rate for Payer: NAPHCARE Commercial |
$821.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,260.11
|
| Rate for Payer: Quartz Beloit One Network |
$671.14
|
| Rate for Payer: Quartz Commercial |
$890.29
|
| Rate for Payer: Quartz Medicare Advantage |
$821.81
|
| Rate for Payer: The Alliance Commercial |
$684.84
|
| Rate for Payer: WEA Trust Commercial |
$753.32
|
| Rate for Payer: WPS Commercial |
$1,014.49
|
|
|
Ambulatory Recovery Charge-Ped
|
Facility
|
OP
|
$1,315.00
|
|
| Hospital Charge Code |
3243534
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$382.93 |
| Max. Negotiated Rate |
$1,258.19 |
| Rate for Payer: Aetna Commercial |
$1,230.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,176.14
|
| Rate for Payer: Aetna Managed Medicare |
$382.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$888.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$683.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$656.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$724.83
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,258.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$765.33
|
| Rate for Payer: Health EOS Commercial |
$1,217.16
|
| Rate for Payer: HFN Commercial |
$1,258.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,025.70
|
| Rate for Payer: Multiplan Commercial |
$1,094.08
|
| Rate for Payer: NAPHCARE Commercial |
$820.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,258.19
|
| Rate for Payer: Quartz Beloit One Network |
$670.12
|
| Rate for Payer: Quartz Commercial |
$888.94
|
| Rate for Payer: Quartz Medicare Advantage |
$820.56
|
| Rate for Payer: The Alliance Commercial |
$683.80
|
| Rate for Payer: WEA Trust Commercial |
$752.18
|
| Rate for Payer: WPS Commercial |
$1,012.94
|
|
|
Ambulatory Recovery Charge-Ped
|
Facility
|
IP
|
$1,315.00
|
|
| Hospital Charge Code |
3243534
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$670.12 |
| Max. Negotiated Rate |
$1,258.19 |
| Rate for Payer: Aetna Commercial |
$1,230.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,176.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$724.83
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,258.19
|
| Rate for Payer: Health EOS Commercial |
$1,217.16
|
| Rate for Payer: HFN Commercial |
$1,258.19
|
| Rate for Payer: Multiplan Commercial |
$1,094.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,258.19
|
| Rate for Payer: Quartz Beloit One Network |
$670.12
|
| Rate for Payer: Quartz Commercial |
$820.56
|
| Rate for Payer: WEA Trust Commercial |
$752.18
|
| Rate for Payer: WPS Commercial |
$1,012.94
|
|
|
Ambulatory Recovery-Minor
|
Facility
|
OP
|
$234.00
|
|
| Hospital Charge Code |
3243536
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$68.14 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Aetna Managed Medicare |
$68.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.19
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.52
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: NAPHCARE Commercial |
$146.02
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$158.18
|
| Rate for Payer: Quartz Medicare Advantage |
$146.02
|
| Rate for Payer: The Alliance Commercial |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
Ambulatory Recovery-Minor
|
Facility
|
IP
|
$234.00
|
|
| Hospital Charge Code |
3243536
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
Ambulatory surgical boot eac L3260
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
3133577
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Ambulatory surgical boot eac L3260
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
3133577
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$32.95 |
| Max. Negotiated Rate |
$71.14 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$71.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.93
|
| Rate for Payer: Health EOS Commercial |
$68.14
|
| Rate for Payer: HFN Commercial |
$71.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.64
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$71.14
|
| Rate for Payer: Quartz Beloit One Network |
$32.95
|
| Rate for Payer: Quartz Commercial |
$42.68
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Ambulatory surgical boot eac L3260
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
3133577
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Amikacin
|
Professional
|
Both
|
$331.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
3595599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$327.03 |
| Rate for Payer: Aetna Commercial |
$327.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Medicare Advantage |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.68
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$327.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$313.26
|
| Rate for Payer: HFN Commercial |
$327.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.68
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| Rate for Payer: Preferred Network Access Commercial |
$327.03
|
| Rate for Payer: Quartz Beloit One Network |
$151.47
|
| Rate for Payer: Quartz Commercial |
$196.22
|
| Rate for Payer: Quartz Medicare Advantage |
$15.68
|
| Rate for Payer: The Alliance Commercial |
$61.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.68
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: WPS Commercial |
$69.01
|
|
|
Amikacin
|
Facility
|
IP
|
$331.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
3595599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$168.68 |
| Max. Negotiated Rate |
$316.70 |
| Rate for Payer: Aetna Commercial |
$309.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.45
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$316.70
|
| Rate for Payer: Health EOS Commercial |
$306.37
|
| Rate for Payer: HFN Commercial |
$316.70
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: Preferred Network Access Commercial |
$316.70
|
| Rate for Payer: Quartz Beloit One Network |
$168.68
|
| Rate for Payer: Quartz Commercial |
$206.54
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: WPS Commercial |
$254.97
|
|
|
Amikacin
|
Facility
|
OP
|
$331.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
3595599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$316.70 |
| Rate for Payer: Aetna Commercial |
$309.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.05
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.45
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.03
|
| Rate for Payer: Anthem Medicare Advantage |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.68
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$316.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$306.37
|
| Rate for Payer: HFN Commercial |
$316.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.68
|
| Rate for Payer: Multiplan Commercial |
$275.39
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| Rate for Payer: Preferred Network Access Commercial |
$316.70
|
| Rate for Payer: Quartz Beloit One Network |
$168.68
|
| Rate for Payer: Quartz Commercial |
$223.76
|
| Rate for Payer: Quartz Medicare Advantage |
$15.68
|
| Rate for Payer: The Alliance Commercial |
$62.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.68
|
| Rate for Payer: United Healthcare PPO |
$258.18
|
| Rate for Payer: WEA Trust Commercial |
$189.33
|
| Rate for Payer: Wellcare Medicare |
$15.68
|
| Rate for Payer: WPS Commercial |
$254.97
|
|
|
Amikacin Level Peak
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
633646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$136.66
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Amikacin Level Peak
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
633646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$216.37 |
| Rate for Payer: Aetna Commercial |
$216.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Medicare Advantage |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.68
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$216.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$207.26
|
| Rate for Payer: HFN Commercial |
$216.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.68
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| Rate for Payer: Preferred Network Access Commercial |
$216.37
|
| Rate for Payer: Quartz Beloit One Network |
$100.21
|
| Rate for Payer: Quartz Commercial |
$129.82
|
| Rate for Payer: Quartz Medicare Advantage |
$15.68
|
| Rate for Payer: The Alliance Commercial |
$61.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.68
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$69.01
|
|
|
Amikacin Level Peak
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
633646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.45
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.03
|
| Rate for Payer: Anthem Medicare Advantage |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.68
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.68
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$148.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15.68
|
| Rate for Payer: The Alliance Commercial |
$62.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.68
|
| Rate for Payer: United Healthcare PPO |
$170.82
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: Wellcare Medicare |
$15.68
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Amikacin Level Trough
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
633647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.45
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.03
|
| Rate for Payer: Anthem Medicare Advantage |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.68
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.68
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$148.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15.68
|
| Rate for Payer: The Alliance Commercial |
$62.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.68
|
| Rate for Payer: United Healthcare PPO |
$170.82
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: Wellcare Medicare |
$15.68
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
