|
INTRAOCULAR LENS IMPLANT, SECONDARY
|
Facility
|
IP
|
$5,256.00
|
|
| Hospital Charge Code |
2960367
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,678.46 |
| Max. Negotiated Rate |
$5,028.94 |
| Rate for Payer: Aetna Commercial |
$4,919.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.11
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$5,028.94
|
| Rate for Payer: Health EOS Commercial |
$4,864.95
|
| Rate for Payer: HFN Commercial |
$5,028.94
|
| Rate for Payer: Multiplan Commercial |
$4,372.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5,028.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.46
|
| Rate for Payer: Quartz Commercial |
$3,279.74
|
| Rate for Payer: WEA Trust Commercial |
$3,006.43
|
| Rate for Payer: WPS Commercial |
$4,048.70
|
|
|
INTRAOCULAR LENS IMPLANT, SECONDARY
|
Facility
|
OP
|
$5,256.00
|
|
| Hospital Charge Code |
2960367
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,530.55 |
| Max. Negotiated Rate |
$5,028.94 |
| Rate for Payer: Aetna Commercial |
$4,919.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.97
|
| Rate for Payer: Aetna Managed Medicare |
$1,530.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,553.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,733.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,623.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.11
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$5,028.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,058.99
|
| Rate for Payer: Health EOS Commercial |
$4,864.95
|
| Rate for Payer: HFN Commercial |
$5,028.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,099.68
|
| Rate for Payer: Multiplan Commercial |
$4,372.99
|
| Rate for Payer: NAPHCARE Commercial |
$3,279.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5,028.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.46
|
| Rate for Payer: Quartz Commercial |
$3,553.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3,279.74
|
| Rate for Payer: The Alliance Commercial |
$2,733.12
|
| Rate for Payer: WEA Trust Commercial |
$3,006.43
|
| Rate for Payer: WPS Commercial |
$4,048.70
|
|
|
INTRAOCULAR LENS REPOSITIONING
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960344
|
|
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
|
|
|
INTRAOCULAR LENS REPOSITIONING
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960344
|
|
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
|
|
|
INTRAOCULAR PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$50,953.76
|
|
|
Service Code
|
MSDRG 116
|
| Min. Negotiated Rate |
$14,353.56 |
| Max. Negotiated Rate |
$50,953.76 |
| Rate for Payer: Aetna Managed Medicare |
$14,353.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,451.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,239.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,729.12
|
| Rate for Payer: Anthem Medicare Advantage |
$14,353.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,353.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,353.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,353.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,891.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,353.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,128.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,353.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,353.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,353.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,353.56
|
| Rate for Payer: NAPHCARE Commercial |
$21,530.34
|
| Rate for Payer: Quartz Medicare Advantage |
$14,353.56
|
| Rate for Payer: The Alliance Commercial |
$50,953.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,353.56
|
| Rate for Payer: United Healthcare PPO |
$28,905.10
|
| Rate for Payer: Wellcare Medicare |
$14,353.56
|
|
|
INTRAOCULAR PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$33,468.24
|
|
|
Service Code
|
MSDRG 117
|
| Min. Negotiated Rate |
$8,815.18 |
| Max. Negotiated Rate |
$33,468.24 |
| Rate for Payer: Aetna Managed Medicare |
$8,815.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,671.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,144.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,238.11
|
| Rate for Payer: Anthem Medicare Advantage |
$8,815.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,815.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,815.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,815.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,135.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,815.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,303.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,815.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,815.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,815.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,815.18
|
| Rate for Payer: NAPHCARE Commercial |
$13,222.76
|
| Rate for Payer: Quartz Medicare Advantage |
$8,815.18
|
| Rate for Payer: The Alliance Commercial |
$33,468.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,815.18
|
| Rate for Payer: United Healthcare PPO |
$18,920.63
|
| Rate for Payer: Wellcare Medicare |
$8,815.18
|
|
|
INTRAOCULAR RETINAL REPAIR
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960158
|
|
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
|
|
|
INTRAOCULAR RETINAL REPAIR
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960158
|
|
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
|
|
|
Intraoperative identification (e.g., 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
|
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
|
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
|
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
|
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
|
|
|
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
|
|
|
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
|
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 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 (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (list separately in addition to code for primary procedure)
|
Facility
|
OP
|
$303.10
|
|
|
Service Code
|
CPT 96367
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| 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: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| 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: NAPHCARE Commercial |
$113.66
|
| 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: Wellcare Medicare |
$75.77
|
|
