|
LEAD PERM.INTRO.9FR. 6209-S5
|
Facility
|
OP
|
$1,035.00
|
|
| Hospital Charge Code |
2962953
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$289.80 |
| Max. Negotiated Rate |
$4,140.00 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Aetna Managed Medicare |
$289.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$672.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$496.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$548.55
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$952.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$579.19
|
| Rate for Payer: Health EOS Commercial |
$921.15
|
| Rate for Payer: HFN Commercial |
$952.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$776.25
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: NAPHCARE Commercial |
$621.00
|
| Rate for Payer: Preferred Network Access Commercial |
$952.20
|
| Rate for Payer: Quartz Beloit One Network |
$507.15
|
| Rate for Payer: Quartz Commercial |
$672.75
|
| Rate for Payer: Quartz Medicare Advantage |
$621.00
|
| Rate for Payer: The Alliance Commercial |
$4,140.00
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
LEAD SINGLE PIN #304-20
|
Facility
|
OP
|
$33,571.00
|
|
| Hospital Charge Code |
2965002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,399.88 |
| Max. Negotiated Rate |
$134,284.00 |
| Rate for Payer: Aetna Commercial |
$30,213.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,871.06
|
| Rate for Payer: Aetna Managed Medicare |
$9,399.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,821.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,785.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,114.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,792.63
|
| Rate for Payer: Cash Price |
$10,071.30
|
| Rate for Payer: Cigna Commercial |
$30,885.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,786.33
|
| Rate for Payer: Health EOS Commercial |
$29,878.19
|
| Rate for Payer: HFN Commercial |
$30,885.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25,178.25
|
| Rate for Payer: Multiplan Commercial |
$26,856.80
|
| Rate for Payer: NAPHCARE Commercial |
$20,142.60
|
| Rate for Payer: Preferred Network Access Commercial |
$30,885.32
|
| Rate for Payer: Quartz Beloit One Network |
$16,449.79
|
| Rate for Payer: Quartz Commercial |
$21,821.15
|
| Rate for Payer: Quartz Medicare Advantage |
$20,142.60
|
| Rate for Payer: The Alliance Commercial |
$134,284.00
|
| Rate for Payer: WEA Trust Commercial |
$18,464.05
|
| Rate for Payer: WPS Commercial |
$24,866.04
|
|
|
LEAD SINGLE PIN #304-20
|
Facility
|
IP
|
$33,571.00
|
|
| Hospital Charge Code |
2965002
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,449.79 |
| Max. Negotiated Rate |
$30,885.32 |
| Rate for Payer: Aetna Commercial |
$30,213.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28,871.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17,792.63
|
| Rate for Payer: Cash Price |
$10,071.30
|
| Rate for Payer: Cigna Commercial |
$30,885.32
|
| Rate for Payer: Health EOS Commercial |
$29,878.19
|
| Rate for Payer: HFN Commercial |
$30,885.32
|
| Rate for Payer: Multiplan Commercial |
$26,856.80
|
| Rate for Payer: NAPHCARE Commercial |
$20,142.60
|
| Rate for Payer: Preferred Network Access Commercial |
$30,885.32
|
| Rate for Payer: Quartz Beloit One Network |
$16,449.79
|
| Rate for Payer: Quartz Commercial |
$20,142.60
|
| Rate for Payer: WEA Trust Commercial |
$18,464.05
|
| Rate for Payer: WPS Commercial |
$24,866.04
|
|
|
Least Incompatible - Crossmatch AHG Interpretation
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
2952715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$142.20
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$142.20
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
Least Incompatible - Crossmatch AHG Interpretation
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 86922
|
| Hospital Charge Code |
2952715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$154.05
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$177.75
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
Least Incompatible - Crossmatch Immediate Spin Interpretation
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
CPT 86920
|
| Hospital Charge Code |
2952719
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.06 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.40
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$56.40
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
Least Incompatible - Crossmatch Immediate Spin Interpretation
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
CPT 86920
|
| Hospital Charge Code |
2952719
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.06 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$61.10
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$70.50
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
Leflunomide Level
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5096621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Aetna Commercial |
$225.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.50
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$230.00
|
| Rate for Payer: Health EOS Commercial |
$222.50
|
| Rate for Payer: HFN Commercial |
$230.00
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: NAPHCARE Commercial |
$150.00
|
| Rate for Payer: Preferred Network Access Commercial |
$230.00
|
| Rate for Payer: Quartz Beloit One Network |
$122.50
|
| Rate for Payer: Quartz Commercial |
$150.00
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
Leflunomide Level
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5096621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$237.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.00
|
| Rate for Payer: Health EOS Commercial |
$227.50
|
| Rate for Payer: HFN Commercial |
$237.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: Preferred Network Access Commercial |
$237.50
|
| Rate for Payer: Quartz Beloit One Network |
$110.00
|
| Rate for Payer: Quartz Commercial |
$142.50
|
| Rate for Payer: The Alliance Commercial |
$125.00
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
Leflunomide Level
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5096621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Aetna Commercial |
$225.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.00
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$230.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.90
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$222.50
|
| Rate for Payer: HFN Commercial |
$230.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$200.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$230.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$122.50
|
| Rate for Payer: Quartz Commercial |
$162.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$187.50
|
| Rate for Payer: WEA Trust Commercial |
$137.50
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$185.18
|
|
|
LEFT CATH INC INTRA INJ LEFT VEN, CAT BY GRAFT 93459
|
Professional
|
Both
|
$6,029.00
|
|
|
Service Code
|
CPT 93459
|
| Hospital Charge Code |
3015399
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$833.54 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Aetna Commercial |
$5,727.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,184.94
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cigna Commercial |
$5,727.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$833.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,617.40
|
| Rate for Payer: Health EOS Commercial |
$5,486.39
|
| Rate for Payer: HFN Commercial |
$5,727.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,033.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,033.24
|
| Rate for Payer: Multiplan Commercial |
$4,823.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,727.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,652.76
|
| Rate for Payer: Quartz Commercial |
$3,436.53
|
| Rate for Payer: The Alliance Commercial |
$3,014.50
|
| Rate for Payer: United Healthcare Medicaid |
$833.54
|
| Rate for Payer: WEA Trust Commercial |
$3,315.95
|
| Rate for Payer: WPS Commercial |
$4,465.68
|
|
|
LEFT CATH INC INTRA INJ LEFT VEN, CAT BY GRAFT 9345926
|
Professional
|
Both
|
$6,029.00
|
|
|
Service Code
|
CPT 93459 26
|
| Hospital Charge Code |
3015400
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$833.54 |
| Max. Negotiated Rate |
$5,727.55 |
| Rate for Payer: Aetna Commercial |
$5,727.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,184.94
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cash Price |
$1,808.70
|
| Rate for Payer: Cigna Commercial |
$5,727.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$833.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,617.40
|
| Rate for Payer: Health EOS Commercial |
$5,486.39
|
| Rate for Payer: HFN Commercial |
$5,727.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,080.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,080.78
|
| Rate for Payer: Multiplan Commercial |
$4,823.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,727.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,652.76
|
| Rate for Payer: Quartz Commercial |
$3,436.53
|
| Rate for Payer: The Alliance Commercial |
$3,014.50
|
| Rate for Payer: United Healthcare Medicaid |
$833.54
|
| Rate for Payer: WEA Trust Commercial |
$3,315.95
|
| Rate for Payer: WPS Commercial |
$4,465.68
|
|
|
Left - Ear, impacted cerumen removal
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 69209
|
| Hospital Charge Code |
4612685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.04
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Left - Ear, impacted cerumen removal
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 69209
|
| Hospital Charge Code |
4612685
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
LEFT HT CATH INC INTRA INJ LEFT VEN 93458
|
Professional
|
Both
|
$4,775.00
|
|
|
Service Code
|
CPT 93458
|
| Hospital Charge Code |
3015397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$754.62 |
| Max. Negotiated Rate |
$4,536.25 |
| Rate for Payer: Aetna Commercial |
$4,536.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,106.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cigna Commercial |
$4,536.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$754.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,865.00
|
| Rate for Payer: Health EOS Commercial |
$4,345.25
|
| Rate for Payer: HFN Commercial |
$4,536.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,733.93
|
| Rate for Payer: Multiplan Commercial |
$3,820.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,101.00
|
| Rate for Payer: Quartz Commercial |
$2,721.75
|
| Rate for Payer: The Alliance Commercial |
$2,387.50
|
| Rate for Payer: United Healthcare Medicaid |
$754.62
|
| Rate for Payer: WEA Trust Commercial |
$2,626.25
|
| Rate for Payer: WPS Commercial |
$3,536.84
|
|
|
LEFT HT CATH INC INTRA INJ LEFT VEN 9345822
|
Professional
|
Both
|
$5,729.00
|
|
|
Service Code
|
CPT 93458 22
|
| Hospital Charge Code |
5190613
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$754.62 |
| Max. Negotiated Rate |
$5,442.55 |
| Rate for Payer: Aetna Commercial |
$5,442.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,926.94
|
| Rate for Payer: Cash Price |
$1,718.70
|
| Rate for Payer: Cash Price |
$1,718.70
|
| Rate for Payer: Cash Price |
$1,718.70
|
| Rate for Payer: Cigna Commercial |
$5,442.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$754.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,437.40
|
| Rate for Payer: Health EOS Commercial |
$5,213.39
|
| Rate for Payer: HFN Commercial |
$5,442.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,733.93
|
| Rate for Payer: Multiplan Commercial |
$4,583.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,442.55
|
| Rate for Payer: Quartz Beloit One Network |
$2,520.76
|
| Rate for Payer: Quartz Commercial |
$3,265.53
|
| Rate for Payer: The Alliance Commercial |
$2,864.50
|
| Rate for Payer: United Healthcare Medicaid |
$754.62
|
| Rate for Payer: WEA Trust Commercial |
$3,150.95
|
| Rate for Payer: WPS Commercial |
$4,243.47
|
|
|
LEFT HT CATH INC INTRA INJ LEFT VEN 9345826
|
Professional
|
Both
|
$4,775.00
|
|
|
Service Code
|
CPT 93458 26
|
| Hospital Charge Code |
3015398
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$754.62 |
| Max. Negotiated Rate |
$4,536.25 |
| Rate for Payer: Aetna Commercial |
$4,536.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,106.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cash Price |
$1,432.50
|
| Rate for Payer: Cigna Commercial |
$4,536.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$754.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,865.00
|
| Rate for Payer: Health EOS Commercial |
$4,345.25
|
| Rate for Payer: HFN Commercial |
$4,536.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$953.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$953.56
|
| Rate for Payer: Multiplan Commercial |
$3,820.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,101.00
|
| Rate for Payer: Quartz Commercial |
$2,721.75
|
| Rate for Payer: The Alliance Commercial |
$2,387.50
|
| Rate for Payer: United Healthcare Medicaid |
$754.62
|
| Rate for Payer: WEA Trust Commercial |
$2,626.25
|
| Rate for Payer: WPS Commercial |
$3,536.84
|
|
|
Legal Blood Draw
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
CPT 36415
|
| Hospital Charge Code |
4254040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.00
|
| Rate for Payer: Health EOS Commercial |
$40.95
|
| Rate for Payer: HFN Commercial |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$42.75
|
| Rate for Payer: Quartz Beloit One Network |
$19.80
|
| Rate for Payer: Quartz Commercial |
$25.65
|
| Rate for Payer: The Alliance Commercial |
$22.50
|
| Rate for Payer: United Healthcare Medicaid |
$7.06
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
Legal Blood Draw
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 36415
|
| Hospital Charge Code |
4254040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Aetna Managed Medicare |
$8.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.60
|
| Rate for Payer: Anthem Medicare Advantage |
$8.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.57
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.57
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.57
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$12.86
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$29.25
|
| Rate for Payer: Quartz Medicare Advantage |
$8.57
|
| Rate for Payer: The Alliance Commercial |
$34.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.57
|
| Rate for Payer: United Healthcare PPO |
$33.75
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: Wellcare Medicare |
$8.57
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
Legal Blood Draw
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 36415
|
| Hospital Charge Code |
4254040
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.00
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
LEG, EXTERNAL FIXATOR
|
Facility
|
IP
|
$5,199.00
|
|
| Hospital Charge Code |
2960040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,547.51 |
| Max. Negotiated Rate |
$4,783.08 |
| Rate for Payer: Aetna Commercial |
$4,679.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,471.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,755.47
|
| Rate for Payer: Cash Price |
$1,559.70
|
| Rate for Payer: Cigna Commercial |
$4,783.08
|
| Rate for Payer: Health EOS Commercial |
$4,627.11
|
| Rate for Payer: HFN Commercial |
$4,783.08
|
| Rate for Payer: Multiplan Commercial |
$4,159.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,783.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,547.51
|
| Rate for Payer: Quartz Commercial |
$3,119.40
|
| Rate for Payer: WEA Trust Commercial |
$2,859.45
|
| Rate for Payer: WPS Commercial |
$3,850.90
|
|
|
LEG, EXTERNAL FIXATOR
|
Facility
|
OP
|
$5,199.00
|
|
| Hospital Charge Code |
2960040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,455.72 |
| Max. Negotiated Rate |
$20,796.00 |
| Rate for Payer: Aetna Commercial |
$4,679.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,471.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,455.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,379.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,599.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,495.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,755.47
|
| Rate for Payer: Cash Price |
$1,559.70
|
| Rate for Payer: Cigna Commercial |
$4,783.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,909.36
|
| Rate for Payer: Health EOS Commercial |
$4,627.11
|
| Rate for Payer: HFN Commercial |
$4,783.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,899.25
|
| Rate for Payer: Multiplan Commercial |
$4,159.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,783.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,547.51
|
| Rate for Payer: Quartz Commercial |
$3,379.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,119.40
|
| Rate for Payer: The Alliance Commercial |
$20,796.00
|
| Rate for Payer: WEA Trust Commercial |
$2,859.45
|
| Rate for Payer: WPS Commercial |
$3,850.90
|
|
|
LEG FASCIOTOMY, LOWER
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2950481
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
LEG FASCIOTOMY, LOWER
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2950481
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
LEGGINGS 89408
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
2963429
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
