|
LASSO CRESCENT QUICKPASS AR-6068C
|
Facility
|
IP
|
$2,347.00
|
|
| Hospital Charge Code |
5385160
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,196.03 |
| Max. Negotiated Rate |
$2,245.61 |
| Rate for Payer: Aetna Commercial |
$2,196.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,099.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,293.67
|
| Rate for Payer: Cash Price |
$704.10
|
| Rate for Payer: Cigna Commercial |
$2,245.61
|
| Rate for Payer: Health EOS Commercial |
$2,172.38
|
| Rate for Payer: HFN Commercial |
$2,245.61
|
| Rate for Payer: Multiplan Commercial |
$1,952.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,245.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,196.03
|
| Rate for Payer: Quartz Commercial |
$1,464.53
|
| Rate for Payer: WEA Trust Commercial |
$1,342.48
|
| Rate for Payer: WPS Commercial |
$1,807.89
|
|
|
Latanoprost 0.005% Ophth Solution 2.5ml [Med]
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2974953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
Latanoprost 0.005% Ophth Solution 2.5ml [Med]
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2974953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
LATERAL RETINACULAR RELEASE, OPEN
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 27425
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,105.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) <=2.5cm 12051
|
Professional
|
Both
|
$418.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
3013602
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.32 |
| Max. Negotiated Rate |
$654.83 |
| Rate for Payer: Aetna Commercial |
$412.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.86
|
| Rate for Payer: Aetna Managed Medicare |
$145.52
|
| Rate for Payer: Anthem Medicare Advantage |
$145.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$145.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$145.52
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$412.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.52
|
| Rate for Payer: Health EOS Commercial |
$395.60
|
| Rate for Payer: HFN Commercial |
$412.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$585.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$585.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$145.52
|
| Rate for Payer: Multiplan Commercial |
$347.78
|
| Rate for Payer: NAPHCARE Commercial |
$218.28
|
| Rate for Payer: Preferred Network Access Commercial |
$412.98
|
| Rate for Payer: Quartz Beloit One Network |
$191.28
|
| Rate for Payer: Quartz Commercial |
$247.79
|
| Rate for Payer: Quartz Medicare Advantage |
$145.52
|
| Rate for Payer: The Alliance Commercial |
$618.45
|
| Rate for Payer: United Healthcare Medicaid |
$108.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$145.52
|
| Rate for Payer: WEA Trust Commercial |
$239.10
|
| Rate for Payer: WPS Commercial |
$654.83
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 2.6-5.0cm 12052
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
3013603
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$154.56 |
| Max. Negotiated Rate |
$758.07 |
| Rate for Payer: Aetna Commercial |
$554.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.76
|
| Rate for Payer: Aetna Managed Medicare |
$168.46
|
| Rate for Payer: Anthem Medicare Advantage |
$168.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.46
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$554.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$154.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.46
|
| Rate for Payer: Health EOS Commercial |
$530.93
|
| Rate for Payer: HFN Commercial |
$554.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$691.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$691.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.46
|
| Rate for Payer: Multiplan Commercial |
$466.75
|
| Rate for Payer: NAPHCARE Commercial |
$252.69
|
| Rate for Payer: Preferred Network Access Commercial |
$554.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.71
|
| Rate for Payer: Quartz Commercial |
$332.56
|
| Rate for Payer: Quartz Medicare Advantage |
$168.46
|
| Rate for Payer: The Alliance Commercial |
$715.95
|
| Rate for Payer: United Healthcare Medicaid |
$154.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.46
|
| Rate for Payer: WEA Trust Commercial |
$320.89
|
| Rate for Payer: WPS Commercial |
$758.07
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 5.1-7.5cm 12053
|
Professional
|
Both
|
$779.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
3013604
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$156.69 |
| Max. Negotiated Rate |
$819.28 |
| Rate for Payer: Aetna Commercial |
$769.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$696.74
|
| Rate for Payer: Aetna Managed Medicare |
$182.06
|
| Rate for Payer: Anthem Medicare Advantage |
$182.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$182.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$182.06
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cigna Commercial |
$769.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.06
|
| Rate for Payer: Health EOS Commercial |
$737.25
|
| Rate for Payer: HFN Commercial |
$769.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$743.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$182.06
|
| Rate for Payer: Multiplan Commercial |
$648.13
|
| Rate for Payer: NAPHCARE Commercial |
$273.09
|
| Rate for Payer: Preferred Network Access Commercial |
$769.65
|
| Rate for Payer: Quartz Beloit One Network |
$356.47
|
| Rate for Payer: Quartz Commercial |
$461.79
|
| Rate for Payer: Quartz Medicare Advantage |
$182.06
|
| Rate for Payer: The Alliance Commercial |
$773.77
|
| Rate for Payer: United Healthcare Medicaid |
$156.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$182.06
|
| Rate for Payer: WEA Trust Commercial |
$445.59
|
| Rate for Payer: WPS Commercial |
$819.28
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 7.6-12.5cm 12054
|
Professional
|
Both
|
$1,279.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
3013605
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$189.80 |
| Max. Negotiated Rate |
$1,263.65 |
| Rate for Payer: Aetna Commercial |
$1,263.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.94
|
| Rate for Payer: Aetna Managed Medicare |
$189.80
|
| Rate for Payer: Anthem Medicare Advantage |
$189.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$189.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$189.80
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cigna Commercial |
$1,263.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$214.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.80
|
| Rate for Payer: Health EOS Commercial |
$1,210.45
|
| Rate for Payer: HFN Commercial |
$1,263.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$748.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$748.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$189.80
|
| Rate for Payer: Multiplan Commercial |
$1,064.13
|
| Rate for Payer: NAPHCARE Commercial |
$284.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.65
|
| Rate for Payer: Quartz Beloit One Network |
$585.27
|
| Rate for Payer: Quartz Commercial |
$758.19
|
| Rate for Payer: Quartz Medicare Advantage |
$189.80
|
| Rate for Payer: The Alliance Commercial |
$806.65
|
| Rate for Payer: United Healthcare Medicaid |
$214.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$189.80
|
| Rate for Payer: WEA Trust Commercial |
$731.59
|
| Rate for Payer: WPS Commercial |
$854.10
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 12.6-20.0cm 12045
|
Professional
|
Both
|
$1,077.00
|
|
|
Service Code
|
CPT 12045
|
| Hospital Charge Code |
3013601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$188.03 |
| Max. Negotiated Rate |
$1,156.90 |
| Rate for Payer: Aetna Commercial |
$1,064.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$963.27
|
| Rate for Payer: Aetna Managed Medicare |
$257.09
|
| Rate for Payer: Anthem Medicare Advantage |
$257.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$257.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$257.09
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cigna Commercial |
$1,064.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$188.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.09
|
| Rate for Payer: Health EOS Commercial |
$1,019.27
|
| Rate for Payer: HFN Commercial |
$1,064.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$924.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$924.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$257.09
|
| Rate for Payer: Multiplan Commercial |
$896.06
|
| Rate for Payer: NAPHCARE Commercial |
$385.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.08
|
| Rate for Payer: Quartz Beloit One Network |
$492.84
|
| Rate for Payer: Quartz Commercial |
$638.45
|
| Rate for Payer: Quartz Medicare Advantage |
$257.09
|
| Rate for Payer: The Alliance Commercial |
$1,092.62
|
| Rate for Payer: United Healthcare Medicaid |
$188.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$257.09
|
| Rate for Payer: WEA Trust Commercial |
$616.04
|
| Rate for Payer: WPS Commercial |
$1,156.90
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) <=2.5cm 12041
|
Professional
|
Both
|
$388.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
3013598
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$567.59 |
| Rate for Payer: Aetna Commercial |
$383.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.03
|
| Rate for Payer: Aetna Managed Medicare |
$126.13
|
| Rate for Payer: Anthem Medicare Advantage |
$126.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.13
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$383.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.13
|
| Rate for Payer: Health EOS Commercial |
$367.20
|
| Rate for Payer: HFN Commercial |
$383.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$503.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.13
|
| Rate for Payer: Multiplan Commercial |
$322.82
|
| Rate for Payer: NAPHCARE Commercial |
$189.20
|
| Rate for Payer: Preferred Network Access Commercial |
$383.34
|
| Rate for Payer: Quartz Beloit One Network |
$177.55
|
| Rate for Payer: Quartz Commercial |
$230.01
|
| Rate for Payer: Quartz Medicare Advantage |
$126.13
|
| Rate for Payer: The Alliance Commercial |
$536.06
|
| Rate for Payer: United Healthcare Medicaid |
$72.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.13
|
| Rate for Payer: WEA Trust Commercial |
$221.94
|
| Rate for Payer: WPS Commercial |
$567.59
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 2.6-7.5cm 12042
|
Professional
|
Both
|
$590.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
3013599
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$105.10 |
| Max. Negotiated Rate |
$742.11 |
| Rate for Payer: Aetna Commercial |
$582.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$527.70
|
| Rate for Payer: Aetna Managed Medicare |
$164.91
|
| Rate for Payer: Anthem Medicare Advantage |
$164.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$164.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$164.91
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$582.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$164.91
|
| Rate for Payer: Health EOS Commercial |
$558.38
|
| Rate for Payer: HFN Commercial |
$582.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$680.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$680.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$164.91
|
| Rate for Payer: Multiplan Commercial |
$490.88
|
| Rate for Payer: NAPHCARE Commercial |
$247.37
|
| Rate for Payer: Preferred Network Access Commercial |
$582.92
|
| Rate for Payer: Quartz Beloit One Network |
$269.98
|
| Rate for Payer: Quartz Commercial |
$349.75
|
| Rate for Payer: Quartz Medicare Advantage |
$164.91
|
| Rate for Payer: The Alliance Commercial |
$700.88
|
| Rate for Payer: United Healthcare Medicaid |
$105.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$164.91
|
| Rate for Payer: WEA Trust Commercial |
$337.48
|
| Rate for Payer: WPS Commercial |
$742.11
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) >30.0cm 12047
|
Professional
|
Both
|
$2,341.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
5404640
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$284.95 |
| Max. Negotiated Rate |
$2,312.91 |
| Rate for Payer: Aetna Commercial |
$2,312.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,093.79
|
| Rate for Payer: Aetna Managed Medicare |
$322.35
|
| Rate for Payer: Anthem Medicare Advantage |
$322.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$322.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$322.35
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cigna Commercial |
$2,312.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$284.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$322.35
|
| Rate for Payer: Health EOS Commercial |
$2,215.52
|
| Rate for Payer: HFN Commercial |
$2,312.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,190.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,190.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$322.35
|
| Rate for Payer: Multiplan Commercial |
$1,947.71
|
| Rate for Payer: NAPHCARE Commercial |
$483.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,312.91
|
| Rate for Payer: Quartz Beloit One Network |
$1,071.24
|
| Rate for Payer: Quartz Commercial |
$1,387.74
|
| Rate for Payer: Quartz Medicare Advantage |
$322.35
|
| Rate for Payer: The Alliance Commercial |
$1,369.98
|
| Rate for Payer: United Healthcare Medicaid |
$284.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$322.35
|
| Rate for Payer: WEA Trust Commercial |
$1,339.05
|
| Rate for Payer: WPS Commercial |
$1,450.57
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 7.6-12.5cm 12044
|
Professional
|
Both
|
$765.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
3013600
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$140.99 |
| Max. Negotiated Rate |
$830.79 |
| Rate for Payer: Aetna Commercial |
$755.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$684.22
|
| Rate for Payer: Aetna Managed Medicare |
$184.62
|
| Rate for Payer: Anthem Medicare Advantage |
$184.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$184.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$184.62
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cigna Commercial |
$755.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$140.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.62
|
| Rate for Payer: Health EOS Commercial |
$724.00
|
| Rate for Payer: HFN Commercial |
$755.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$735.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$735.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$184.62
|
| Rate for Payer: Multiplan Commercial |
$636.48
|
| Rate for Payer: NAPHCARE Commercial |
$276.93
|
| Rate for Payer: Preferred Network Access Commercial |
$755.82
|
| Rate for Payer: Quartz Beloit One Network |
$350.06
|
| Rate for Payer: Quartz Commercial |
$453.49
|
| Rate for Payer: Quartz Medicare Advantage |
$184.62
|
| Rate for Payer: The Alliance Commercial |
$784.64
|
| Rate for Payer: United Healthcare Medicaid |
$140.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$184.62
|
| Rate for Payer: WEA Trust Commercial |
$437.58
|
| Rate for Payer: WPS Commercial |
$830.79
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 12.6-20.0cm 12035
|
Professional
|
Both
|
$1,016.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
3013595
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$204.64 |
| Max. Negotiated Rate |
$1,003.81 |
| Rate for Payer: Aetna Commercial |
$1,003.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$908.71
|
| Rate for Payer: Aetna Managed Medicare |
$214.60
|
| Rate for Payer: Anthem Medicare Advantage |
$214.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$214.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$214.60
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$1,003.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.60
|
| Rate for Payer: Health EOS Commercial |
$961.54
|
| Rate for Payer: HFN Commercial |
$1,003.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$824.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$824.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$214.60
|
| Rate for Payer: Multiplan Commercial |
$845.31
|
| Rate for Payer: NAPHCARE Commercial |
$321.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,003.81
|
| Rate for Payer: Quartz Beloit One Network |
$464.92
|
| Rate for Payer: Quartz Commercial |
$602.28
|
| Rate for Payer: Quartz Medicare Advantage |
$214.60
|
| Rate for Payer: The Alliance Commercial |
$912.07
|
| Rate for Payer: United Healthcare Medicaid |
$204.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$214.60
|
| Rate for Payer: WEA Trust Commercial |
$581.15
|
| Rate for Payer: WPS Commercial |
$965.72
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 20.1-30.0cm 12036
|
Professional
|
Both
|
$1,180.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
3013596
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$219.36 |
| Max. Negotiated Rate |
$1,165.84 |
| Rate for Payer: Aetna Commercial |
$1,165.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,055.39
|
| Rate for Payer: Aetna Managed Medicare |
$254.90
|
| Rate for Payer: Anthem Medicare Advantage |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$254.90
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$1,165.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$254.90
|
| Rate for Payer: Health EOS Commercial |
$1,116.75
|
| Rate for Payer: HFN Commercial |
$1,165.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$962.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$962.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$254.90
|
| Rate for Payer: Multiplan Commercial |
$981.76
|
| Rate for Payer: NAPHCARE Commercial |
$382.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,165.84
|
| Rate for Payer: Quartz Beloit One Network |
$539.97
|
| Rate for Payer: Quartz Commercial |
$699.50
|
| Rate for Payer: Quartz Medicare Advantage |
$254.90
|
| Rate for Payer: The Alliance Commercial |
$1,083.34
|
| Rate for Payer: United Healthcare Medicaid |
$219.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$254.90
|
| Rate for Payer: WEA Trust Commercial |
$674.96
|
| Rate for Payer: WPS Commercial |
$1,147.07
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) <= 2.5cm 12031
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
3013592
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$586.92 |
| Rate for Payer: Aetna Commercial |
$482.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.47
|
| Rate for Payer: Aetna Managed Medicare |
$130.43
|
| Rate for Payer: Anthem Medicare Advantage |
$130.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.43
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$482.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.43
|
| Rate for Payer: Health EOS Commercial |
$461.84
|
| Rate for Payer: HFN Commercial |
$482.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$525.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.43
|
| Rate for Payer: Multiplan Commercial |
$406.02
|
| Rate for Payer: NAPHCARE Commercial |
$195.64
|
| Rate for Payer: Preferred Network Access Commercial |
$482.14
|
| Rate for Payer: Quartz Beloit One Network |
$223.31
|
| Rate for Payer: Quartz Commercial |
$289.29
|
| Rate for Payer: Quartz Medicare Advantage |
$130.43
|
| Rate for Payer: The Alliance Commercial |
$554.31
|
| Rate for Payer: United Healthcare Medicaid |
$61.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.43
|
| Rate for Payer: WEA Trust Commercial |
$279.14
|
| Rate for Payer: WPS Commercial |
$586.92
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 2.6-7.5cm 12032
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
3013593
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.09 |
| Max. Negotiated Rate |
$729.52 |
| Rate for Payer: Aetna Commercial |
$503.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$456.14
|
| Rate for Payer: Aetna Managed Medicare |
$162.12
|
| Rate for Payer: Anthem Medicare Advantage |
$162.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$162.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$162.12
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$503.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.12
|
| Rate for Payer: Health EOS Commercial |
$482.66
|
| Rate for Payer: HFN Commercial |
$503.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$659.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$659.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$162.12
|
| Rate for Payer: Multiplan Commercial |
$424.32
|
| Rate for Payer: NAPHCARE Commercial |
$243.17
|
| Rate for Payer: Preferred Network Access Commercial |
$503.88
|
| Rate for Payer: Quartz Beloit One Network |
$233.38
|
| Rate for Payer: Quartz Commercial |
$302.33
|
| Rate for Payer: Quartz Medicare Advantage |
$162.12
|
| Rate for Payer: The Alliance Commercial |
$688.99
|
| Rate for Payer: United Healthcare Medicaid |
$84.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$162.12
|
| Rate for Payer: WEA Trust Commercial |
$291.72
|
| Rate for Payer: WPS Commercial |
$729.52
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) >30.0cm 12037
|
Professional
|
Both
|
$1,605.00
|
|
|
Service Code
|
CPT 12037
|
| Hospital Charge Code |
3013597
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$263.21 |
| Max. Negotiated Rate |
$1,585.74 |
| Rate for Payer: Aetna Commercial |
$1,585.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,435.51
|
| Rate for Payer: Aetna Managed Medicare |
$289.45
|
| Rate for Payer: Anthem Medicare Advantage |
$289.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$289.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$289.45
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cigna Commercial |
$1,585.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.45
|
| Rate for Payer: Health EOS Commercial |
$1,518.97
|
| Rate for Payer: HFN Commercial |
$1,585.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,114.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,114.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$289.45
|
| Rate for Payer: Multiplan Commercial |
$1,335.36
|
| Rate for Payer: NAPHCARE Commercial |
$434.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,585.74
|
| Rate for Payer: Quartz Beloit One Network |
$734.45
|
| Rate for Payer: Quartz Commercial |
$951.44
|
| Rate for Payer: Quartz Medicare Advantage |
$289.45
|
| Rate for Payer: The Alliance Commercial |
$1,230.17
|
| Rate for Payer: United Healthcare Medicaid |
$263.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$289.45
|
| Rate for Payer: WEA Trust Commercial |
$918.06
|
| Rate for Payer: WPS Commercial |
$1,302.54
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 7.6-12.5cm 12034
|
Professional
|
Both
|
$474.00
|
|
|
Service Code
|
CPT 12034
|
| Hospital Charge Code |
3013594
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$125.34 |
| Max. Negotiated Rate |
$786.57 |
| Rate for Payer: Aetna Commercial |
$468.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$423.95
|
| Rate for Payer: Aetna Managed Medicare |
$174.79
|
| Rate for Payer: Anthem Medicare Advantage |
$174.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$174.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$174.79
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cigna Commercial |
$468.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.79
|
| Rate for Payer: Health EOS Commercial |
$448.59
|
| Rate for Payer: HFN Commercial |
$468.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$709.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$709.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$174.79
|
| Rate for Payer: Multiplan Commercial |
$394.37
|
| Rate for Payer: NAPHCARE Commercial |
$262.19
|
| Rate for Payer: Preferred Network Access Commercial |
$468.31
|
| Rate for Payer: Quartz Beloit One Network |
$216.90
|
| Rate for Payer: Quartz Commercial |
$280.99
|
| Rate for Payer: Quartz Medicare Advantage |
$174.79
|
| Rate for Payer: The Alliance Commercial |
$742.87
|
| Rate for Payer: United Healthcare Medicaid |
$125.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$174.79
|
| Rate for Payer: WEA Trust Commercial |
$271.13
|
| Rate for Payer: WPS Commercial |
$786.57
|
|
|
lbandronate sodium injection 1 mg J1740
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
3761591
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.63 |
| Max. Negotiated Rate |
$424.82 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Aetna Managed Medicare |
$129.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$300.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.63
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$346.32
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: NAPHCARE Commercial |
$277.06
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$300.14
|
| Rate for Payer: Quartz Medicare Advantage |
$277.06
|
| Rate for Payer: The Alliance Commercial |
$54.66
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: WPS Commercial |
$82.45
|
|
|
lbandronate sodium injection 1 mg J1740
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
3761591
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.26 |
| Max. Negotiated Rate |
$424.82 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$277.06
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: WPS Commercial |
$342.01
|
|
|
lbandronate sodium injection 1 mg J1740
|
Professional
|
Both
|
$444.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
3761591
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$438.67 |
| Rate for Payer: Aetna Commercial |
$438.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Aetna Managed Medicare |
$13.67
|
| Rate for Payer: Anthem Medicare Advantage |
$13.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.67
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$438.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.98
|
| Rate for Payer: Health EOS Commercial |
$420.20
|
| Rate for Payer: HFN Commercial |
$438.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.67
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: NAPHCARE Commercial |
$20.50
|
| Rate for Payer: Preferred Network Access Commercial |
$438.67
|
| Rate for Payer: Quartz Beloit One Network |
$203.17
|
| Rate for Payer: Quartz Commercial |
$263.20
|
| Rate for Payer: Quartz Medicare Advantage |
$13.67
|
| Rate for Payer: The Alliance Commercial |
$37.58
|
| Rate for Payer: United Healthcare Medicaid |
$13.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.67
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: WPS Commercial |
$82.45
|
|
|
LD, CSF to Mayo
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
3587539
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
LD, CSF to Mayo
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
3587539
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$6.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.43
|
| Rate for Payer: Anthem Medicare Advantage |
$6.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.28
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.28
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.28
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$9.42
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$6.28
|
| Rate for Payer: The Alliance Commercial |
$25.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.28
|
| Rate for Payer: United Healthcare PPO |
$67.86
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: Wellcare Medicare |
$6.28
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
LD, CSF to Mayo
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
3587539
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$85.96 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$6.28
|
| Rate for Payer: Anthem Medicare Advantage |
$6.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.28
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.28
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.28
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$9.42
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: Quartz Medicare Advantage |
$6.28
|
| Rate for Payer: The Alliance Commercial |
$24.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.28
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$27.64
|
|
