|
LEVEL I SPINE PROCEDURES
|
Facility
|
OP
|
$2,307.44
|
|
|
Service Code
|
EAPG 00028
|
| Min. Negotiated Rate |
$2,218.68 |
| Max. Negotiated Rate |
$2,307.44 |
| Rate for Payer: Anthem Medicaid |
$2,218.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,218.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,218.68
|
| Rate for Payer: Dean Health Medicaid |
$2,218.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,218.68
|
| Rate for Payer: Managed Health Services Medicaid |
$2,307.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,218.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,218.68
|
| Rate for Payer: United Healthcare Medicaid |
$2,218.68
|
|
|
LEVEL I SURGICAL PATHOLOGY TESTS
|
Facility
|
OP
|
$40.62
|
|
|
Service Code
|
EAPG 00305
|
| Min. Negotiated Rate |
$39.06 |
| Max. Negotiated Rate |
$40.62 |
| Rate for Payer: Anthem Medicaid |
$39.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$39.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.06
|
| Rate for Payer: Dean Health Medicaid |
$39.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$39.06
|
| Rate for Payer: Managed Health Services Medicaid |
$40.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$39.06
|
| Rate for Payer: United Healthcare Medicaid |
$39.06
|
|
|
LEVEL I THORACIC AND CHEST PROCEDURES
|
Facility
|
OP
|
$1,284.09
|
|
|
Service Code
|
EAPG 00069
|
| Min. Negotiated Rate |
$1,234.70 |
| Max. Negotiated Rate |
$1,284.09 |
| Rate for Payer: Anthem Medicaid |
$1,234.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,234.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,234.70
|
| Rate for Payer: Dean Health Medicaid |
$1,234.70
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,234.70
|
| Rate for Payer: Managed Health Services Medicaid |
$1,284.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.70
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,234.70
|
| Rate for Payer: United Healthcare Medicaid |
$1,234.70
|
|
|
LEVEL I UPPER GI ENDOSCOPY
|
Facility
|
OP
|
$576.53
|
|
|
Service Code
|
EAPG 00134
|
| Min. Negotiated Rate |
$554.36 |
| Max. Negotiated Rate |
$576.53 |
| Rate for Payer: Anthem Medicaid |
$554.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$554.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$554.36
|
| Rate for Payer: Dean Health Medicaid |
$554.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$554.36
|
| Rate for Payer: Managed Health Services Medicaid |
$576.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$554.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$554.36
|
| Rate for Payer: United Healthcare Medicaid |
$554.36
|
|
|
LEVEL I URETHRAL PROCEDURES
|
Facility
|
OP
|
$718.04
|
|
|
Service Code
|
EAPG 00166
|
| Min. Negotiated Rate |
$690.43 |
| Max. Negotiated Rate |
$718.04 |
| Rate for Payer: Anthem Medicaid |
$690.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$690.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$690.43
|
| Rate for Payer: Dean Health Medicaid |
$690.43
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$690.43
|
| Rate for Payer: Managed Health Services Medicaid |
$718.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$690.43
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$690.43
|
| Rate for Payer: United Healthcare Medicaid |
$690.43
|
|
|
LEVEL I VARICOSE VEIN AND RELATED PROCEDURES
|
Facility
|
OP
|
$749.49
|
|
|
Service Code
|
EAPG 00090
|
| Min. Negotiated Rate |
$720.66 |
| Max. Negotiated Rate |
$749.49 |
| Rate for Payer: Anthem Medicaid |
$720.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$720.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$720.66
|
| Rate for Payer: Dean Health Medicaid |
$720.66
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$720.66
|
| Rate for Payer: Managed Health Services Medicaid |
$749.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$720.66
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$720.66
|
| Rate for Payer: United Healthcare Medicaid |
$720.66
|
|
|
LEVEL I VASCULAR RADIOLOGICAL PROCEDURES
|
Facility
|
OP
|
$227.99
|
|
|
Service Code
|
EAPG 00277
|
| Min. Negotiated Rate |
$219.22 |
| Max. Negotiated Rate |
$227.99 |
| Rate for Payer: Anthem Medicaid |
$219.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$219.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.22
|
| Rate for Payer: Dean Health Medicaid |
$219.22
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$219.22
|
| Rate for Payer: Managed Health Services Medicaid |
$227.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$219.22
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$219.22
|
| Rate for Payer: United Healthcare Medicaid |
$219.22
|
|
|
LEVEL IV EAR, NOSE, MOUTH AND THROAT PROCEDURES
|
Facility
|
OP
|
$2,445.02
|
|
|
Service Code
|
EAPG 00255
|
| Min. Negotiated Rate |
$2,350.97 |
| Max. Negotiated Rate |
$2,445.02 |
| Rate for Payer: Anthem Medicaid |
$2,350.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,350.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,350.97
|
| Rate for Payer: Dean Health Medicaid |
$2,350.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,350.97
|
| Rate for Payer: Managed Health Services Medicaid |
$2,445.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,350.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,350.97
|
| Rate for Payer: United Healthcare Medicaid |
$2,350.97
|
|
|
LEVEL IV NERVE PROCEDURE W OR W/O NEUROLOGICAL DEVICE
|
Facility
|
OP
|
$13,513.12
|
|
|
Service Code
|
EAPG 00224
|
| Min. Negotiated Rate |
$12,993.35 |
| Max. Negotiated Rate |
$13,513.12 |
| Rate for Payer: Anthem Medicaid |
$12,993.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$12,993.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12,993.35
|
| Rate for Payer: Dean Health Medicaid |
$12,993.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12,993.35
|
| Rate for Payer: Managed Health Services Medicaid |
$13,513.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,993.35
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12,993.35
|
| Rate for Payer: United Healthcare Medicaid |
$12,993.35
|
|
|
LEVEL IV ORAL AND MAXILLOFACIAL PROCEDURES
|
Facility
|
OP
|
$272.54
|
|
|
Service Code
|
EAPG 00370
|
| Min. Negotiated Rate |
$262.06 |
| Max. Negotiated Rate |
$272.54 |
| Rate for Payer: Anthem Medicaid |
$262.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$262.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$262.06
|
| Rate for Payer: Dean Health Medicaid |
$262.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$262.06
|
| Rate for Payer: Managed Health Services Medicaid |
$272.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$262.06
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$262.06
|
| Rate for Payer: United Healthcare Medicaid |
$262.06
|
|
|
Levetiracetam Level
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
978008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Levetiracetam Level
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
978008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$13.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.87
|
| Rate for Payer: Anthem Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.78
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.78
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.67
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13.78
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.78
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$13.78
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Levetiracetam Level
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
978008
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$13.78
|
| Rate for Payer: Anthem Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.78
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.78
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.67
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$13.78
|
| Rate for Payer: The Alliance Commercial |
$54.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.78
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$60.63
|
|
|
Levonorgestrel iu contracept J7298
|
Professional
|
Both
|
$1,710.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
4605888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$782.50 |
| Max. Negotiated Rate |
$1,689.48 |
| Rate for Payer: Aetna Commercial |
$1,689.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,529.42
|
| Rate for Payer: Anthem Commercial |
$1,039.25
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cigna Commercial |
$1,689.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,263.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,067.04
|
| Rate for Payer: Health EOS Commercial |
$1,618.34
|
| Rate for Payer: HFN Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,555.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,555.24
|
| Rate for Payer: Multiplan Commercial |
$1,422.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,689.48
|
| Rate for Payer: Quartz Beloit One Network |
$782.50
|
| Rate for Payer: Quartz Commercial |
$1,013.69
|
| Rate for Payer: The Alliance Commercial |
$889.20
|
| Rate for Payer: United Healthcare Medicaid |
$1,263.22
|
| Rate for Payer: WEA Trust Commercial |
$978.12
|
| Rate for Payer: WPS Commercial |
$1,317.21
|
|
|
Levonorgestrel iu contracept J7298
|
Facility
|
IP
|
$1,710.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
4605888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$871.42 |
| Max. Negotiated Rate |
$1,636.13 |
| Rate for Payer: Aetna Commercial |
$1,600.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,529.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$942.55
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cigna Commercial |
$1,636.13
|
| Rate for Payer: Health EOS Commercial |
$1,582.78
|
| Rate for Payer: HFN Commercial |
$1,636.13
|
| Rate for Payer: Multiplan Commercial |
$1,422.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,636.13
|
| Rate for Payer: Quartz Beloit One Network |
$871.42
|
| Rate for Payer: Quartz Commercial |
$1,067.04
|
| Rate for Payer: WEA Trust Commercial |
$978.12
|
| Rate for Payer: WPS Commercial |
$1,317.21
|
|
|
Levonorgestrel iu contracept J7298
|
Facility
|
OP
|
$1,710.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
4605888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.95 |
| Max. Negotiated Rate |
$1,636.13 |
| Rate for Payer: Aetna Commercial |
$1,600.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,529.42
|
| Rate for Payer: Aetna Managed Medicare |
$497.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,155.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$889.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$853.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$942.55
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cigna Commercial |
$1,636.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$995.22
|
| Rate for Payer: Health EOS Commercial |
$1,582.78
|
| Rate for Payer: HFN Commercial |
$1,636.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,333.80
|
| Rate for Payer: Multiplan Commercial |
$1,422.72
|
| Rate for Payer: NAPHCARE Commercial |
$1,067.04
|
| Rate for Payer: Preferred Network Access Commercial |
$1,636.13
|
| Rate for Payer: Quartz Beloit One Network |
$871.42
|
| Rate for Payer: Quartz Commercial |
$1,155.96
|
| Rate for Payer: Quartz Medicare Advantage |
$1,067.04
|
| Rate for Payer: The Alliance Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$978.12
|
| Rate for Payer: WPS Commercial |
$1,317.21
|
|
|
Levonorgestrel-releasing intrauterine contraceptive system J7296
|
Facility
|
OP
|
$2,521.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5366628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$734.12 |
| Max. Negotiated Rate |
$2,412.09 |
| Rate for Payer: Aetna Commercial |
$2,359.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,254.78
|
| Rate for Payer: Aetna Managed Medicare |
$734.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,704.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,310.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,258.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,389.58
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cigna Commercial |
$2,412.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,467.22
|
| Rate for Payer: Health EOS Commercial |
$2,333.44
|
| Rate for Payer: HFN Commercial |
$2,412.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,966.38
|
| Rate for Payer: Multiplan Commercial |
$2,097.47
|
| Rate for Payer: NAPHCARE Commercial |
$1,573.10
|
| Rate for Payer: Preferred Network Access Commercial |
$2,412.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,284.70
|
| Rate for Payer: Quartz Commercial |
$1,704.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,573.10
|
| Rate for Payer: The Alliance Commercial |
$1,310.92
|
| Rate for Payer: WEA Trust Commercial |
$1,442.01
|
| Rate for Payer: WPS Commercial |
$1,941.93
|
|
|
Levonorgestrel-releasing intrauterine contraceptive system J7296
|
Professional
|
Both
|
$2,521.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5366628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,039.25 |
| Max. Negotiated Rate |
$2,490.75 |
| Rate for Payer: Aetna Commercial |
$2,490.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,254.78
|
| Rate for Payer: Anthem Commercial |
$1,039.25
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cigna Commercial |
$2,490.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,263.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,573.10
|
| Rate for Payer: Health EOS Commercial |
$2,385.87
|
| Rate for Payer: HFN Commercial |
$2,490.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,547.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,547.66
|
| Rate for Payer: Multiplan Commercial |
$2,097.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,490.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,153.61
|
| Rate for Payer: Quartz Commercial |
$1,494.45
|
| Rate for Payer: The Alliance Commercial |
$1,310.92
|
| Rate for Payer: United Healthcare Medicaid |
$1,263.22
|
| Rate for Payer: WEA Trust Commercial |
$1,442.01
|
| Rate for Payer: WPS Commercial |
$1,941.93
|
|
|
Levonorgestrel-releasing intrauterine contraceptive system J7296
|
Facility
|
IP
|
$2,521.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
5366628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,284.70 |
| Max. Negotiated Rate |
$2,412.09 |
| Rate for Payer: Aetna Commercial |
$2,359.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,254.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,389.58
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cigna Commercial |
$2,412.09
|
| Rate for Payer: Health EOS Commercial |
$2,333.44
|
| Rate for Payer: HFN Commercial |
$2,412.09
|
| Rate for Payer: Multiplan Commercial |
$2,097.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,412.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,284.70
|
| Rate for Payer: Quartz Commercial |
$1,573.10
|
| Rate for Payer: WEA Trust Commercial |
$1,442.01
|
| Rate for Payer: WPS Commercial |
$1,941.93
|
|
|
LHC Coronaries/BPG w/wo LV
|
Facility
|
OP
|
$21,101.00
|
|
|
Service Code
|
CPT 93459
|
| Hospital Charge Code |
3052499
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,411.77 |
| Max. Negotiated Rate |
$20,189.44 |
| Rate for Payer: Aetna Commercial |
$19,750.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,872.73
|
| Rate for Payer: Aetna Managed Medicare |
$3,411.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,530.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,753.44
|
| Rate for Payer: Anthem Medicare Advantage |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,630.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,411.77
|
| Rate for Payer: Cash Price |
$6,330.30
|
| Rate for Payer: Cash Price |
$6,330.30
|
| Rate for Payer: Cash Price |
$6,330.30
|
| Rate for Payer: Cigna Commercial |
$20,189.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,411.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,411.77
|
| Rate for Payer: Health EOS Commercial |
$19,531.09
|
| Rate for Payer: HFN Commercial |
$20,189.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,691.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,411.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,411.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,411.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,411.77
|
| Rate for Payer: Multiplan Commercial |
$17,556.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,117.66
|
| Rate for Payer: Preferred Network Access Commercial |
$20,189.44
|
| Rate for Payer: Quartz Beloit One Network |
$10,753.07
|
| Rate for Payer: Quartz Commercial |
$14,264.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,411.77
|
| Rate for Payer: The Alliance Commercial |
$13,647.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,411.77
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$12,069.77
|
| Rate for Payer: Wellcare Medicare |
$3,411.77
|
| Rate for Payer: WPS Commercial |
$16,254.10
|
|
|
LHC Coronaries/BPG w/wo LV
|
Facility
|
IP
|
$21,101.00
|
|
|
Service Code
|
CPT 93459
|
| Hospital Charge Code |
3052499
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$10,753.07 |
| Max. Negotiated Rate |
$20,189.44 |
| Rate for Payer: Aetna Commercial |
$19,750.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,872.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,630.87
|
| Rate for Payer: Cash Price |
$6,330.30
|
| Rate for Payer: Cigna Commercial |
$20,189.44
|
| Rate for Payer: Health EOS Commercial |
$19,531.09
|
| Rate for Payer: HFN Commercial |
$20,189.44
|
| Rate for Payer: Multiplan Commercial |
$17,556.03
|
| Rate for Payer: Preferred Network Access Commercial |
$20,189.44
|
| Rate for Payer: Quartz Beloit One Network |
$10,753.07
|
| Rate for Payer: Quartz Commercial |
$13,167.02
|
| Rate for Payer: WEA Trust Commercial |
$12,069.77
|
| Rate for Payer: WPS Commercial |
$16,254.10
|
|
|
LHC Coronaries w/wo LV
|
Facility
|
IP
|
$19,353.00
|
|
|
Service Code
|
CPT 93458
|
| Hospital Charge Code |
3052498
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$9,862.29 |
| Max. Negotiated Rate |
$18,516.95 |
| Rate for Payer: Aetna Commercial |
$18,114.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,309.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,667.37
|
| Rate for Payer: Cash Price |
$5,805.90
|
| Rate for Payer: Cigna Commercial |
$18,516.95
|
| Rate for Payer: Health EOS Commercial |
$17,913.14
|
| Rate for Payer: HFN Commercial |
$18,516.95
|
| Rate for Payer: Multiplan Commercial |
$16,101.70
|
| Rate for Payer: Preferred Network Access Commercial |
$18,516.95
|
| Rate for Payer: Quartz Beloit One Network |
$9,862.29
|
| Rate for Payer: Quartz Commercial |
$12,076.27
|
| Rate for Payer: WEA Trust Commercial |
$11,069.92
|
| Rate for Payer: WPS Commercial |
$14,907.62
|
|
|
LHC Coronaries w/wo LV
|
Facility
|
OP
|
$19,353.00
|
|
|
Service Code
|
CPT 93458
|
| Hospital Charge Code |
3052498
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,411.77 |
| Max. Negotiated Rate |
$18,516.95 |
| Rate for Payer: Aetna Commercial |
$18,114.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,309.32
|
| Rate for Payer: Aetna Managed Medicare |
$3,411.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,530.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,753.44
|
| Rate for Payer: Anthem Medicare Advantage |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,667.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,411.77
|
| Rate for Payer: Cash Price |
$5,805.90
|
| Rate for Payer: Cash Price |
$5,805.90
|
| Rate for Payer: Cash Price |
$5,805.90
|
| Rate for Payer: Cigna Commercial |
$18,516.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,411.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,411.77
|
| Rate for Payer: Health EOS Commercial |
$17,913.14
|
| Rate for Payer: HFN Commercial |
$18,516.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,691.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,411.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,411.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,411.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,411.77
|
| Rate for Payer: Multiplan Commercial |
$16,101.70
|
| Rate for Payer: NAPHCARE Commercial |
$5,117.66
|
| Rate for Payer: Preferred Network Access Commercial |
$18,516.95
|
| Rate for Payer: Quartz Beloit One Network |
$9,862.29
|
| Rate for Payer: Quartz Commercial |
$13,082.63
|
| Rate for Payer: Quartz Medicare Advantage |
$3,411.77
|
| Rate for Payer: The Alliance Commercial |
$13,647.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,411.77
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$11,069.92
|
| Rate for Payer: Wellcare Medicare |
$3,411.77
|
| Rate for Payer: WPS Commercial |
$14,907.62
|
|
|
LHC w/wo LV
|
Facility
|
OP
|
$18,729.00
|
|
|
Service Code
|
CPT 93452
|
| Hospital Charge Code |
3052492
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,411.77 |
| Max. Negotiated Rate |
$18,182.32 |
| Rate for Payer: Aetna Commercial |
$17,530.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,751.22
|
| Rate for Payer: Aetna Managed Medicare |
$3,411.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15,530.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,753.44
|
| Rate for Payer: Anthem Medicare Advantage |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,323.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,411.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,411.77
|
| Rate for Payer: Cash Price |
$5,618.70
|
| Rate for Payer: Cash Price |
$5,618.70
|
| Rate for Payer: Cash Price |
$5,618.70
|
| Rate for Payer: Cigna Commercial |
$17,919.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,411.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,900.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,411.77
|
| Rate for Payer: Health EOS Commercial |
$17,335.56
|
| Rate for Payer: HFN Commercial |
$17,919.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,691.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,411.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,411.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,411.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,411.77
|
| Rate for Payer: Multiplan Commercial |
$15,582.53
|
| Rate for Payer: NAPHCARE Commercial |
$5,117.66
|
| Rate for Payer: Preferred Network Access Commercial |
$17,919.91
|
| Rate for Payer: Quartz Beloit One Network |
$9,544.30
|
| Rate for Payer: Quartz Commercial |
$12,660.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,411.77
|
| Rate for Payer: The Alliance Commercial |
$13,647.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,411.77
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$10,712.99
|
| Rate for Payer: Wellcare Medicare |
$3,411.77
|
| Rate for Payer: WPS Commercial |
$14,426.95
|
|
|
LHC w/wo LV
|
Facility
|
IP
|
$18,729.00
|
|
|
Service Code
|
CPT 93452
|
| Hospital Charge Code |
3052492
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$9,544.30 |
| Max. Negotiated Rate |
$17,919.91 |
| Rate for Payer: Aetna Commercial |
$17,530.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,751.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,323.42
|
| Rate for Payer: Cash Price |
$5,618.70
|
| Rate for Payer: Cigna Commercial |
$17,919.91
|
| Rate for Payer: Health EOS Commercial |
$17,335.56
|
| Rate for Payer: HFN Commercial |
$17,919.91
|
| Rate for Payer: Multiplan Commercial |
$15,582.53
|
| Rate for Payer: Preferred Network Access Commercial |
$17,919.91
|
| Rate for Payer: Quartz Beloit One Network |
$9,544.30
|
| Rate for Payer: Quartz Commercial |
$11,686.90
|
| Rate for Payer: WEA Trust Commercial |
$10,712.99
|
| Rate for Payer: WPS Commercial |
$14,426.95
|
|
