|
Lidocaine 2% with Epi 20ml (Med)
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
5264618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Lidocaine 2% with Epi 20ml (Med)
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
5264618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Lidocaine 2% with Epi 50ml MDV [Med]
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
Lidocaine 2% with Epi 50ml MDV [Med]
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
Lidocaine 4% 5ml Ampule (Med)
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
5286884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.04
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$0.07
|
|
|
Lidocaine 4% 5ml Ampule (Med)
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
5286884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
Lidocaine Injection J2001
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3975039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.03
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.03
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$0.07
|
|
|
Lidocaine Injection J2001
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3975039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Lidocaine Injection J2001
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3975039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.04
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$0.07
|
|
|
Lidocaine Jelly 10ml Urojet [Med]
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
2974958
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Aetna Managed Medicare |
$9.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.59
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$22.75
|
| Rate for Payer: Quartz Medicare Advantage |
$21.00
|
| Rate for Payer: The Alliance Commercial |
$140.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Lidocaine Jelly 10ml Urojet [Med]
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
2974958
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Lidocaine Level
|
Professional
|
Both
|
$159.00
|
|
|
Service Code
|
CPT 80176
|
| Hospital Charge Code |
4598919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.86 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Aetna Commercial |
$151.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$151.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.40
|
| Rate for Payer: Health EOS Commercial |
$144.69
|
| Rate for Payer: HFN Commercial |
$151.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.86
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$151.05
|
| Rate for Payer: Quartz Beloit One Network |
$69.96
|
| Rate for Payer: Quartz Commercial |
$90.63
|
| Rate for Payer: The Alliance Commercial |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
Lidocaine Level
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
CPT 80176
|
| Hospital Charge Code |
4598919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
Lidocaine Level
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
CPT 80176
|
| Hospital Charge Code |
4598919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$14.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.39
|
| Rate for Payer: Anthem Medicaid |
$15.18
|
| Rate for Payer: Anthem Medicare Advantage |
$14.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.69
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Dean Health Medicaid |
$15.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.69
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.69
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.69
|
| Rate for Payer: Managed Health Services Medicaid |
$15.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.69
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.04
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.18
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$14.69
|
| Rate for Payer: The Alliance Commercial |
$58.76
|
| Rate for Payer: United Healthcare Medicaid |
$15.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.69
|
| Rate for Payer: United Healthcare PPO |
$119.25
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: Wellcare Medicare |
$14.69
|
| Rate for Payer: WMAP Medicaid |
$15.18
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
Lidocaine MPF 1% 2ml vial [Med]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
2974896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.04
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$0.07
|
|
|
Lidocaine MPF 1% 2ml vial [Med]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
2974896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Lidocaine PF 1% 30ml SDV [Med]
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
5286881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.04
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$0.07
|
|
|
Lidocaine PF 1% 30ml SDV [Med]
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
5286881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
lidocaine Top 2% Gel 5 gm [Med]
|
Facility
|
OP
|
$47.00
|
|
| Hospital Charge Code |
2983103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Aetna Managed Medicare |
$13.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.30
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.25
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$30.55
|
| Rate for Payer: Quartz Medicare Advantage |
$28.20
|
| Rate for Payer: The Alliance Commercial |
$188.00
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
lidocaine Top 2% Gel 5 gm [Med]
|
Facility
|
IP
|
$47.00
|
|
| Hospital Charge Code |
2983103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.03 |
| Max. Negotiated Rate |
$43.24 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$28.20
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
Li-Fraumuni Syndrome
|
Professional
|
Both
|
$790.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
5426837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$347.60 |
| Max. Negotiated Rate |
$1,063.77 |
| Rate for Payer: Aetna Commercial |
$750.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$750.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$395.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$474.00
|
| Rate for Payer: Health EOS Commercial |
$718.90
|
| Rate for Payer: HFN Commercial |
$750.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,063.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,063.77
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: Preferred Network Access Commercial |
$750.50
|
| Rate for Payer: Quartz Beloit One Network |
$347.60
|
| Rate for Payer: Quartz Commercial |
$450.30
|
| Rate for Payer: The Alliance Commercial |
$395.00
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
|
Li-Fraumuni Syndrome
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
5426837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$301.35 |
| Max. Negotiated Rate |
$1,205.40 |
| Rate for Payer: Aetna Commercial |
$711.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Aetna Managed Medicare |
$301.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,130.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$527.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$500.24
|
| Rate for Payer: Anthem Medicaid |
$301.35
|
| Rate for Payer: Anthem Medicare Advantage |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$418.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$301.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$301.35
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$726.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$301.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$442.08
|
| Rate for Payer: Dean Health Medicaid |
$301.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$301.35
|
| Rate for Payer: Health EOS Commercial |
$703.10
|
| Rate for Payer: HFN Commercial |
$726.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,121.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$301.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$301.35
|
| Rate for Payer: Managed Health Services Medicaid |
$313.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$301.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$301.35
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: NAPHCARE Commercial |
$452.02
|
| Rate for Payer: Preferred Network Access Commercial |
$726.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$301.35
|
| Rate for Payer: Quartz Beloit One Network |
$387.10
|
| Rate for Payer: Quartz Commercial |
$513.50
|
| Rate for Payer: Quartz Medicare Advantage |
$301.35
|
| Rate for Payer: The Alliance Commercial |
$1,205.40
|
| Rate for Payer: United Healthcare Medicaid |
$301.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$301.35
|
| Rate for Payer: United Healthcare PPO |
$592.50
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: Wellcare Medicare |
$301.35
|
| Rate for Payer: WMAP Medicaid |
$301.35
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
|
Li-Fraumuni Syndrome
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
5426837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$387.10 |
| Max. Negotiated Rate |
$726.80 |
| Rate for Payer: Aetna Commercial |
$711.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$679.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$418.70
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$726.80
|
| Rate for Payer: Health EOS Commercial |
$703.10
|
| Rate for Payer: HFN Commercial |
$726.80
|
| Rate for Payer: Multiplan Commercial |
$632.00
|
| Rate for Payer: NAPHCARE Commercial |
$474.00
|
| Rate for Payer: Preferred Network Access Commercial |
$726.80
|
| Rate for Payer: Quartz Beloit One Network |
$387.10
|
| Rate for Payer: Quartz Commercial |
$474.00
|
| Rate for Payer: WEA Trust Commercial |
$434.50
|
| Rate for Payer: WPS Commercial |
$585.15
|
|
|
LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR
|
Facility
|
OP
|
$28,284.48
|
|
|
Service Code
|
CPT 27427
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,546.14 |
| Max. Negotiated Rate |
$28,284.48 |
| Rate for Payer: Aetna Managed Medicare |
$7,071.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,483.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,278.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,071.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,071.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,071.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,304.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,071.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,071.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,071.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,071.12
|
| Rate for Payer: NAPHCARE Commercial |
$10,606.68
|
| Rate for Payer: Quartz Medicare Advantage |
$7,071.12
|
| Rate for Payer: The Alliance Commercial |
$28,284.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,071.12
|
| Rate for Payer: United Healthcare PPO |
$8,452.00
|
| Rate for Payer: Wellcare Medicare |
$7,071.12
|
|
|
LIGASURE 10MM LAPAROSCOPIC SEAL LS1037
|
Facility
|
IP
|
$5,028.00
|
|
| Hospital Charge Code |
2975073
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,463.72 |
| Max. Negotiated Rate |
$4,625.76 |
| Rate for Payer: Aetna Commercial |
$4,525.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,324.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,664.84
|
| Rate for Payer: Cash Price |
$1,508.40
|
| Rate for Payer: Cigna Commercial |
$4,625.76
|
| Rate for Payer: Health EOS Commercial |
$4,474.92
|
| Rate for Payer: HFN Commercial |
$4,625.76
|
| Rate for Payer: Multiplan Commercial |
$4,022.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,016.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,625.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,463.72
|
| Rate for Payer: Quartz Commercial |
$3,016.80
|
| Rate for Payer: WEA Trust Commercial |
$2,765.40
|
| Rate for Payer: WPS Commercial |
$3,724.24
|
|
