|
INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 38900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$450.82 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: The Alliance Commercial |
$450.82
|
|
|
INTRAOP FEE NERVE ACTION
|
Facility
|
IP
|
$11,592.00
|
|
| Hospital Charge Code |
2967913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5,907.28 |
| Max. Negotiated Rate |
$11,091.23 |
| Rate for Payer: Aetna Commercial |
$10,850.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,367.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,389.51
|
| Rate for Payer: Cash Price |
$3,477.60
|
| Rate for Payer: Cigna Commercial |
$11,091.23
|
| Rate for Payer: Health EOS Commercial |
$10,729.56
|
| Rate for Payer: HFN Commercial |
$11,091.23
|
| Rate for Payer: Multiplan Commercial |
$9,644.54
|
| Rate for Payer: Preferred Network Access Commercial |
$11,091.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,907.28
|
| Rate for Payer: Quartz Commercial |
$7,233.41
|
| Rate for Payer: WEA Trust Commercial |
$6,630.62
|
| Rate for Payer: WPS Commercial |
$8,929.32
|
|
|
INTRAOP FEE NERVE ACTION
|
Facility
|
OP
|
$11,592.00
|
|
| Hospital Charge Code |
2967913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3,375.59 |
| Max. Negotiated Rate |
$11,091.23 |
| Rate for Payer: Aetna Commercial |
$10,850.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,367.88
|
| Rate for Payer: Aetna Managed Medicare |
$3,375.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,836.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,027.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,786.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,389.51
|
| Rate for Payer: Cash Price |
$3,477.60
|
| Rate for Payer: Cigna Commercial |
$11,091.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,746.54
|
| Rate for Payer: Health EOS Commercial |
$10,729.56
|
| Rate for Payer: HFN Commercial |
$11,091.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,041.76
|
| Rate for Payer: Multiplan Commercial |
$9,644.54
|
| Rate for Payer: NAPHCARE Commercial |
$7,233.41
|
| Rate for Payer: Preferred Network Access Commercial |
$11,091.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,907.28
|
| Rate for Payer: Quartz Commercial |
$7,836.19
|
| Rate for Payer: Quartz Medicare Advantage |
$7,233.41
|
| Rate for Payer: The Alliance Commercial |
$6,027.84
|
| Rate for Payer: WEA Trust Commercial |
$6,630.62
|
| Rate for Payer: WPS Commercial |
$8,929.32
|
|
|
Intra Op TEE Ea Add HR
|
Facility
|
IP
|
$1,431.00
|
|
| Hospital Charge Code |
1158930
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$729.24 |
| Max. Negotiated Rate |
$1,369.18 |
| Rate for Payer: Aetna Commercial |
$1,339.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,279.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$788.77
|
| Rate for Payer: Cash Price |
$429.30
|
| Rate for Payer: Cigna Commercial |
$1,369.18
|
| Rate for Payer: Health EOS Commercial |
$1,324.53
|
| Rate for Payer: HFN Commercial |
$1,369.18
|
| Rate for Payer: Multiplan Commercial |
$1,190.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,369.18
|
| Rate for Payer: Quartz Beloit One Network |
$729.24
|
| Rate for Payer: Quartz Commercial |
$892.94
|
| Rate for Payer: WEA Trust Commercial |
$818.53
|
| Rate for Payer: WPS Commercial |
$1,102.30
|
|
|
Intra Op TEE Ea Add HR
|
Facility
|
OP
|
$1,431.00
|
|
| Hospital Charge Code |
1158930
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$416.71 |
| Max. Negotiated Rate |
$1,369.18 |
| Rate for Payer: Aetna Commercial |
$1,339.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,279.89
|
| Rate for Payer: Aetna Managed Medicare |
$416.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$967.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$744.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$714.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$788.77
|
| Rate for Payer: Cash Price |
$429.30
|
| Rate for Payer: Cigna Commercial |
$1,369.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$832.84
|
| Rate for Payer: Health EOS Commercial |
$1,324.53
|
| Rate for Payer: HFN Commercial |
$1,369.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,116.18
|
| Rate for Payer: Multiplan Commercial |
$1,190.59
|
| Rate for Payer: NAPHCARE Commercial |
$892.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,369.18
|
| Rate for Payer: Quartz Beloit One Network |
$729.24
|
| Rate for Payer: Quartz Commercial |
$967.36
|
| Rate for Payer: Quartz Medicare Advantage |
$892.94
|
| Rate for Payer: The Alliance Commercial |
$744.12
|
| Rate for Payer: United Healthcare PPO |
$1,116.18
|
| Rate for Payer: WEA Trust Commercial |
$818.53
|
| Rate for Payer: WPS Commercial |
$1,102.30
|
|
|
Intra Op TEE Ea Add HR
|
Professional
|
Both
|
$1,431.00
|
|
| Hospital Charge Code |
1158930
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$654.83 |
| Max. Negotiated Rate |
$1,413.83 |
| Rate for Payer: Aetna Commercial |
$1,413.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,279.89
|
| Rate for Payer: Cash Price |
$429.30
|
| Rate for Payer: Cigna Commercial |
$1,413.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$744.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$892.94
|
| Rate for Payer: Health EOS Commercial |
$1,354.30
|
| Rate for Payer: HFN Commercial |
$1,413.83
|
| Rate for Payer: Multiplan Commercial |
$1,190.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,413.83
|
| Rate for Payer: Quartz Beloit One Network |
$654.83
|
| Rate for Payer: Quartz Commercial |
$848.30
|
| Rate for Payer: The Alliance Commercial |
$744.12
|
| Rate for Payer: WEA Trust Commercial |
$818.53
|
| Rate for Payer: WPS Commercial |
$1,102.30
|
|
|
INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE 41009
|
Professional
|
Both
|
$1,724.00
|
|
|
Service Code
|
CPT 41009
|
| Hospital Charge Code |
6187325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.06 |
| Max. Negotiated Rate |
$1,703.31 |
| Rate for Payer: Aetna Commercial |
$1,703.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.95
|
| Rate for Payer: Aetna Managed Medicare |
$257.67
|
| Rate for Payer: Anthem Medicare Advantage |
$257.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$257.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$257.67
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cash Price |
$517.20
|
| Rate for Payer: Cigna Commercial |
$1,703.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.67
|
| Rate for Payer: Health EOS Commercial |
$1,631.59
|
| Rate for Payer: HFN Commercial |
$1,703.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$993.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$257.67
|
| Rate for Payer: Multiplan Commercial |
$1,434.37
|
| Rate for Payer: NAPHCARE Commercial |
$386.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,703.31
|
| Rate for Payer: Quartz Beloit One Network |
$788.90
|
| Rate for Payer: Quartz Commercial |
$1,021.99
|
| Rate for Payer: Quartz Medicare Advantage |
$257.67
|
| Rate for Payer: The Alliance Commercial |
$1,095.10
|
| Rate for Payer: United Healthcare Medicaid |
$63.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.67
|
| Rate for Payer: WEA Trust Commercial |
$986.13
|
| Rate for Payer: WPS Commercial |
$1,159.52
|
|
|
Intraut copper contraceptive J7300 man
|
Professional
|
Both
|
$2,707.00
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
3373613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$974.48 |
| Max. Negotiated Rate |
$2,674.52 |
| Rate for Payer: Aetna Commercial |
$2,674.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,421.14
|
| Rate for Payer: Anthem Commercial |
$974.48
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cigna Commercial |
$2,674.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,184.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,689.17
|
| Rate for Payer: Health EOS Commercial |
$2,561.90
|
| Rate for Payer: HFN Commercial |
$2,674.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,376.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,376.60
|
| Rate for Payer: Multiplan Commercial |
$2,252.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,674.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,238.72
|
| Rate for Payer: Quartz Commercial |
$1,604.71
|
| Rate for Payer: The Alliance Commercial |
$1,407.64
|
| Rate for Payer: United Healthcare Medicaid |
$1,184.56
|
| Rate for Payer: WEA Trust Commercial |
$1,548.40
|
| Rate for Payer: WPS Commercial |
$2,085.20
|
|
|
Intraut copper contraceptive J7300 man
|
Facility
|
OP
|
$2,707.00
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
3373613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$788.28 |
| Max. Negotiated Rate |
$2,590.06 |
| Rate for Payer: Aetna Commercial |
$2,533.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,421.14
|
| Rate for Payer: Aetna Managed Medicare |
$788.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,829.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,407.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,351.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,492.10
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cigna Commercial |
$2,590.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,575.47
|
| Rate for Payer: Health EOS Commercial |
$2,505.60
|
| Rate for Payer: HFN Commercial |
$2,590.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,111.46
|
| Rate for Payer: Multiplan Commercial |
$2,252.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,689.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,590.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,379.49
|
| Rate for Payer: Quartz Commercial |
$1,829.93
|
| Rate for Payer: Quartz Medicare Advantage |
$1,689.17
|
| Rate for Payer: The Alliance Commercial |
$1,407.64
|
| Rate for Payer: WEA Trust Commercial |
$1,548.40
|
| Rate for Payer: WPS Commercial |
$2,085.20
|
|
|
Intraut copper contraceptive J7300 man
|
Facility
|
IP
|
$2,707.00
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
3373613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,379.49 |
| Max. Negotiated Rate |
$2,590.06 |
| Rate for Payer: Aetna Commercial |
$2,533.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,421.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,492.10
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cigna Commercial |
$2,590.06
|
| Rate for Payer: Health EOS Commercial |
$2,505.60
|
| Rate for Payer: HFN Commercial |
$2,590.06
|
| Rate for Payer: Multiplan Commercial |
$2,252.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,590.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,379.49
|
| Rate for Payer: Quartz Commercial |
$1,689.17
|
| Rate for Payer: WEA Trust Commercial |
$1,548.40
|
| Rate for Payer: WPS Commercial |
$2,085.20
|
|
|
INTRAVASC US, HEART ADD-ON 9297826
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
CPT 92978 26
|
| Hospital Charge Code |
3015352
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.95 |
| Max. Negotiated Rate |
$671.84 |
| Rate for Payer: Aetna Commercial |
$671.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$608.19
|
| Rate for Payer: Aetna Managed Medicare |
$86.95
|
| Rate for Payer: Anthem Medicare Advantage |
$86.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$86.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$86.95
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$671.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.95
|
| Rate for Payer: Health EOS Commercial |
$643.55
|
| Rate for Payer: HFN Commercial |
$671.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$319.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$319.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$86.95
|
| Rate for Payer: Multiplan Commercial |
$565.76
|
| Rate for Payer: NAPHCARE Commercial |
$130.43
|
| Rate for Payer: Preferred Network Access Commercial |
$671.84
|
| Rate for Payer: Quartz Beloit One Network |
$311.17
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: Quartz Medicare Advantage |
$86.95
|
| Rate for Payer: The Alliance Commercial |
$330.43
|
| Rate for Payer: United Healthcare Medicaid |
$98.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.95
|
| Rate for Payer: WEA Trust Commercial |
$388.96
|
| Rate for Payer: WPS Commercial |
$347.82
|
|
|
INTRAVASC US, HEART ADD-ON 9297926
|
Professional
|
Both
|
$567.00
|
|
|
Service Code
|
CPT 92979 26
|
| Hospital Charge Code |
3015354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$69.16 |
| Max. Negotiated Rate |
$560.20 |
| Rate for Payer: Aetna Commercial |
$560.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.12
|
| Rate for Payer: Aetna Managed Medicare |
$69.16
|
| Rate for Payer: Anthem Medicare Advantage |
$69.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.16
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: Cigna Commercial |
$560.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.16
|
| Rate for Payer: Health EOS Commercial |
$536.61
|
| Rate for Payer: HFN Commercial |
$560.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$254.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.16
|
| Rate for Payer: Multiplan Commercial |
$471.74
|
| Rate for Payer: NAPHCARE Commercial |
$103.74
|
| Rate for Payer: Preferred Network Access Commercial |
$560.20
|
| Rate for Payer: Quartz Beloit One Network |
$259.46
|
| Rate for Payer: Quartz Commercial |
$336.12
|
| Rate for Payer: Quartz Medicare Advantage |
$69.16
|
| Rate for Payer: The Alliance Commercial |
$262.81
|
| Rate for Payer: United Healthcare Medicaid |
$78.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.16
|
| Rate for Payer: WEA Trust Commercial |
$324.32
|
| Rate for Payer: WPS Commercial |
$276.64
|
|
|
INTRAVENOUS CUTDOWN
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
INTRAVENOUS CUTDOWN
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
Intravenous Infusion for therapy, prophylaxis or diagnosis; initial up to 1 Hr 96366
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
5516706
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$134.53 |
| Max. Negotiated Rate |
$252.60 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.52
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$252.60
|
| Rate for Payer: Health EOS Commercial |
$244.36
|
| Rate for Payer: HFN Commercial |
$252.60
|
| Rate for Payer: Multiplan Commercial |
$219.65
|
| Rate for Payer: Preferred Network Access Commercial |
$252.60
|
| Rate for Payer: Quartz Beloit One Network |
$134.53
|
| Rate for Payer: Quartz Commercial |
$164.74
|
| Rate for Payer: WEA Trust Commercial |
$151.01
|
| Rate for Payer: WPS Commercial |
$203.36
|
|
|
Intravenous Infusion for therapy, prophylaxis or diagnosis; initial up to 1 Hr 96366
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
5516706
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$252.60 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.12
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.79
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$252.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$244.36
|
| Rate for Payer: HFN Commercial |
$252.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$219.65
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$252.60
|
| Rate for Payer: Quartz Beloit One Network |
$134.53
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$151.01
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$203.36
|
|
|
Intravenous Injection
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
CPT 96374
|
| Hospital Charge Code |
3040224
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$174.22 |
| Max. Negotiated Rate |
$895.40 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Aetna Managed Medicare |
$223.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$181.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.22
|
| Rate for Payer: Anthem Medicare Advantage |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$223.85
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$223.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$223.85
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$832.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$223.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$223.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$223.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$223.85
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: NAPHCARE Commercial |
$335.77
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$235.92
|
| Rate for Payer: Quartz Medicare Advantage |
$223.85
|
| Rate for Payer: The Alliance Commercial |
$895.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$223.85
|
| Rate for Payer: United Healthcare PPO |
$272.22
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: Wellcare Medicare |
$223.85
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Intravenous Injection
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
CPT 96374
|
| Hospital Charge Code |
3040224
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$217.78
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Intravenous Injection - 96374
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
CPT 96374
|
| Hospital Charge Code |
5516710
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$174.22 |
| Max. Negotiated Rate |
$895.40 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Aetna Managed Medicare |
$223.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$181.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.22
|
| Rate for Payer: Anthem Medicare Advantage |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$223.85
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$223.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$223.85
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$832.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$223.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$223.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$223.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$223.85
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: NAPHCARE Commercial |
$335.77
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$235.92
|
| Rate for Payer: Quartz Medicare Advantage |
$223.85
|
| Rate for Payer: The Alliance Commercial |
$895.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$223.85
|
| Rate for Payer: United Healthcare PPO |
$272.22
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: Wellcare Medicare |
$223.85
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Intravenous Injection - 96374
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
CPT 96374
|
| Hospital Charge Code |
5516710
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$217.78
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Intravenous Therapy Additional Sequential of a New Drug/Substance up to an hour - 96367
|
Facility
|
OP
|
$388.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
5516707
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$371.24 |
| Rate for Payer: Aetna Commercial |
$363.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$201.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$193.69
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.87
|
| 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 |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$371.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$359.13
|
| Rate for Payer: HFN Commercial |
$371.24
|
| 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 |
$322.82
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$371.24
|
| Rate for Payer: Quartz Beloit One Network |
$197.72
|
| Rate for Payer: Quartz Commercial |
$262.29
|
| 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 |
$302.64
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$298.88
|
|
|
Intravenous Therapy Additional Sequential of a New Drug/Substance up to an hour - 96367
|
Facility
|
IP
|
$388.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
5516707
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$197.72 |
| Max. Negotiated Rate |
$371.24 |
| Rate for Payer: Aetna Commercial |
$363.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.87
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$371.24
|
| Rate for Payer: Health EOS Commercial |
$359.13
|
| Rate for Payer: HFN Commercial |
$371.24
|
| Rate for Payer: Multiplan Commercial |
$322.82
|
| Rate for Payer: Preferred Network Access Commercial |
$371.24
|
| Rate for Payer: Quartz Beloit One Network |
$197.72
|
| Rate for Payer: Quartz Commercial |
$242.11
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: WPS Commercial |
$298.88
|
|
|
Intravitreal Injection Of Pharmacologic Agent
|
Professional
|
Both
|
$698.00
|
|
|
Service Code
|
CPT 67028
|
| Hospital Charge Code |
1188935
|
|
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
|
|
|
Intrinsic Factor Antibody
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 86340
|
| Hospital Charge Code |
977999
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
Intrinsic Factor Antibody
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 86340
|
| Hospital Charge Code |
977999
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| 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 |
$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 |
$149.93
|
| 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 |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.68
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| 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 |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$23.52
|
| 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 |
$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 |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: Wellcare Medicare |
$15.68
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
