|
Lovenox 10 mg Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
2958914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Lovenox 10 mg Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
2958914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.62
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$1.55
|
|
|
Low - Blood Glucose Hi/Lo
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.73 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$46.20
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$46.20
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Low - Blood Glucose Hi/Lo
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
3052355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$70.84 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.37
|
| Rate for Payer: Anthem Medicaid |
$4.45
|
| Rate for Payer: Anthem Medicare Advantage |
$5.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.04
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$70.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.09
|
| Rate for Payer: Dean Health Medicaid |
$4.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.04
|
| Rate for Payer: Health EOS Commercial |
$68.53
|
| Rate for Payer: HFN Commercial |
$70.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.04
|
| Rate for Payer: Managed Health Services Medicaid |
$4.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: NAPHCARE Commercial |
$7.56
|
| Rate for Payer: Preferred Network Access Commercial |
$70.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.45
|
| Rate for Payer: Quartz Beloit One Network |
$37.73
|
| Rate for Payer: Quartz Commercial |
$50.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5.04
|
| Rate for Payer: The Alliance Commercial |
$20.16
|
| Rate for Payer: United Healthcare Medicaid |
$4.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.04
|
| Rate for Payer: United Healthcare PPO |
$57.75
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: Wellcare Medicare |
$5.04
|
| Rate for Payer: WMAP Medicaid |
$4.45
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
LOW COST SKIN SUBSTITUTE APP (add'l 100 sq cm) C5274
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS C5274
|
| Hospital Charge Code |
6242709
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
LOW COST SKIN SUBSTITUTE APP (up to 100 sq cm) C5273
|
Professional
|
Both
|
$369.00
|
|
|
Service Code
|
HCPCS C5273
|
| Hospital Charge Code |
6242708
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$162.36 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$350.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$350.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$184.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.40
|
| Rate for Payer: Health EOS Commercial |
$335.79
|
| Rate for Payer: HFN Commercial |
$350.55
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$350.55
|
| Rate for Payer: Quartz Beloit One Network |
$162.36
|
| Rate for Payer: Quartz Commercial |
$210.33
|
| Rate for Payer: The Alliance Commercial |
$184.50
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$64,172.00
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$23,083.44 |
| Max. Negotiated Rate |
$64,172.00 |
| Rate for Payer: Aetna Managed Medicare |
$23,083.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50,352.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38,594.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36,667.20
|
| Rate for Payer: Anthem Medicare Advantage |
$23,083.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23,083.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23,083.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23,083.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40,703.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23,083.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46,833.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23,083.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23,083.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23,083.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23,083.44
|
| Rate for Payer: NAPHCARE Commercial |
$34,625.16
|
| Rate for Payer: Quartz Medicare Advantage |
$23,083.44
|
| Rate for Payer: The Alliance Commercial |
$64,172.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23,083.44
|
| Rate for Payer: United Healthcare PPO |
$36,460.21
|
| Rate for Payer: Wellcare Medicare |
$23,083.44
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$92,364.00
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$33,224.35 |
| Max. Negotiated Rate |
$92,364.00 |
| Rate for Payer: Aetna Managed Medicare |
$33,224.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72,590.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55,640.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52,861.88
|
| Rate for Payer: Anthem Medicare Advantage |
$33,224.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33,224.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33,224.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33,224.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58,681.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33,224.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67,510.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33,224.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33,224.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33,224.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33,224.35
|
| Rate for Payer: NAPHCARE Commercial |
$49,836.52
|
| Rate for Payer: Quartz Medicare Advantage |
$33,224.35
|
| Rate for Payer: The Alliance Commercial |
$92,364.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33,224.35
|
| Rate for Payer: United Healthcare PPO |
$52,558.14
|
| Rate for Payer: Wellcare Medicare |
$33,224.35
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$50,015.00
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$17,990.98 |
| Max. Negotiated Rate |
$50,015.00 |
| Rate for Payer: NAPHCARE Commercial |
$26,986.47
|
| Rate for Payer: Quartz Medicare Advantage |
$17,990.98
|
| Rate for Payer: The Alliance Commercial |
$50,015.00
|
| Rate for Payer: Aetna Managed Medicare |
$17,990.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,232.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,071.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,569.86
|
| Rate for Payer: Anthem Medicare Advantage |
$17,990.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,990.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,990.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,990.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,715.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,990.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,449.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,990.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,990.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,990.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,990.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,990.98
|
| Rate for Payer: United Healthcare PPO |
$28,376.33
|
| Rate for Payer: Wellcare Medicare |
$17,990.98
|
|
|
LOWER EXTREMITY STUDY 9392526
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 93925 26
|
| Hospital Charge Code |
3015434
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$107.36 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$205.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.40
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: HFN Commercial |
$231.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$129.37
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: The Alliance Commercial |
$122.00
|
| Rate for Payer: United Healthcare Medicaid |
$205.54
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Loxapine
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.60 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Aetna Commercial |
$310.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Aetna Managed Medicare |
$96.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$224.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.85
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$317.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.06
|
| Rate for Payer: Health EOS Commercial |
$307.05
|
| Rate for Payer: HFN Commercial |
$317.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.75
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: NAPHCARE Commercial |
$207.00
|
| Rate for Payer: Preferred Network Access Commercial |
$317.40
|
| Rate for Payer: Quartz Beloit One Network |
$169.05
|
| Rate for Payer: Quartz Commercial |
$224.25
|
| Rate for Payer: Quartz Medicare Advantage |
$207.00
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: United Healthcare PPO |
$258.75
|
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
|
|
Loxapine
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
| Rate for Payer: Aetna Commercial |
$327.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$327.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.00
|
| Rate for Payer: Health EOS Commercial |
$313.95
|
| Rate for Payer: HFN Commercial |
$327.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$327.75
|
| Rate for Payer: Quartz Beloit One Network |
$151.80
|
| Rate for Payer: Quartz Commercial |
$196.65
|
| Rate for Payer: The Alliance Commercial |
$172.50
|
|
|
Loxapine
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983306
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.05 |
| Max. Negotiated Rate |
$317.40 |
| Rate for Payer: Aetna Commercial |
$310.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.85
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$317.40
|
| Rate for Payer: Health EOS Commercial |
$307.05
|
| Rate for Payer: HFN Commercial |
$317.40
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: NAPHCARE Commercial |
$207.00
|
| Rate for Payer: Preferred Network Access Commercial |
$317.40
|
| Rate for Payer: Quartz Beloit One Network |
$169.05
|
| Rate for Payer: Quartz Commercial |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
|
|
LPE Interpretation
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.31 |
| Max. Negotiated Rate |
$246.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$61.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$230.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.09
|
| Rate for Payer: Anthem Medicaid |
$48.31
|
| Rate for Payer: Anthem Medicare Advantage |
$61.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$61.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$61.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$61.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.95
|
| Rate for Payer: Dean Health Medicaid |
$48.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$61.50
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$48.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$61.50
|
| Rate for Payer: Managed Health Services Medicaid |
$50.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$61.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$92.25
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$48.31
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.50
|
| Rate for Payer: The Alliance Commercial |
$246.00
|
| Rate for Payer: United Healthcare Medicaid |
$48.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$61.50
|
| Rate for Payer: United Healthcare PPO |
$93.75
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: Wellcare Medicare |
$61.50
|
| Rate for Payer: WMAP Medicaid |
$48.31
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
LPE Interpretation
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
LPE Interpretation
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$217.10 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$118.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.00
|
| Rate for Payer: Health EOS Commercial |
$113.75
|
| Rate for Payer: HFN Commercial |
$118.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$217.10
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: Preferred Network Access Commercial |
$118.75
|
| Rate for Payer: Quartz Beloit One Network |
$55.00
|
| Rate for Payer: Quartz Commercial |
$71.25
|
| Rate for Payer: The Alliance Commercial |
$62.50
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT LT 249.689
|
Facility
|
OP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$722.96 |
| Max. Negotiated Rate |
$10,328.00 |
| Rate for Payer: Aetna Commercial |
$2,323.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,220.52
|
| Rate for Payer: Aetna Managed Medicare |
$722.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,678.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,291.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,239.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.46
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,375.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,444.89
|
| Rate for Payer: Health EOS Commercial |
$2,297.98
|
| Rate for Payer: HFN Commercial |
$2,375.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,936.50
|
| Rate for Payer: Multiplan Commercial |
$2,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,375.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.18
|
| Rate for Payer: Quartz Commercial |
$1,678.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,549.20
|
| Rate for Payer: The Alliance Commercial |
$10,328.00
|
| Rate for Payer: WEA Trust Commercial |
$1,420.10
|
| Rate for Payer: WPS Commercial |
$1,912.49
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT LT 249.689
|
Facility
|
IP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170026
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.18 |
| Max. Negotiated Rate |
$2,375.44 |
| Rate for Payer: Aetna Commercial |
$2,323.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,220.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.46
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,375.44
|
| Rate for Payer: Health EOS Commercial |
$2,297.98
|
| Rate for Payer: HFN Commercial |
$2,375.44
|
| Rate for Payer: Multiplan Commercial |
$2,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,375.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.18
|
| Rate for Payer: Quartz Commercial |
$1,549.20
|
| Rate for Payer: WEA Trust Commercial |
$1,420.10
|
| Rate for Payer: WPS Commercial |
$1,912.49
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT RT 249.688
|
Facility
|
OP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$722.96 |
| Max. Negotiated Rate |
$10,328.00 |
| Rate for Payer: Aetna Commercial |
$2,323.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,220.52
|
| Rate for Payer: Aetna Managed Medicare |
$722.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,678.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,291.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,239.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.46
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,375.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,444.89
|
| Rate for Payer: Health EOS Commercial |
$2,297.98
|
| Rate for Payer: HFN Commercial |
$2,375.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,936.50
|
| Rate for Payer: Multiplan Commercial |
$2,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,375.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.18
|
| Rate for Payer: Quartz Commercial |
$1,678.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,549.20
|
| Rate for Payer: The Alliance Commercial |
$10,328.00
|
| Rate for Payer: WEA Trust Commercial |
$1,420.10
|
| Rate for Payer: WPS Commercial |
$1,912.49
|
|
|
L- PLATE 2.7 LCP 2HL HEAD/3HL SHAFT RT 249.688
|
Facility
|
IP
|
$2,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6170038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.18 |
| Max. Negotiated Rate |
$2,375.44 |
| Rate for Payer: Aetna Commercial |
$2,323.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,220.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,368.46
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,375.44
|
| Rate for Payer: Health EOS Commercial |
$2,297.98
|
| Rate for Payer: HFN Commercial |
$2,375.44
|
| Rate for Payer: Multiplan Commercial |
$2,065.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,549.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,375.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,265.18
|
| Rate for Payer: Quartz Commercial |
$1,549.20
|
| Rate for Payer: WEA Trust Commercial |
$1,420.10
|
| Rate for Payer: WPS Commercial |
$1,912.49
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 3 X 4HL RT 0.8 THICK TI 04.503.386
|
Facility
|
IP
|
$4,433.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,172.17 |
| Max. Negotiated Rate |
$4,078.36 |
| Rate for Payer: Aetna Commercial |
$3,989.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,812.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,349.49
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,078.36
|
| Rate for Payer: Health EOS Commercial |
$3,945.37
|
| Rate for Payer: HFN Commercial |
$4,078.36
|
| Rate for Payer: Multiplan Commercial |
$3,546.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,659.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,078.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,172.17
|
| Rate for Payer: Quartz Commercial |
$2,659.80
|
| Rate for Payer: WEA Trust Commercial |
$2,438.15
|
| Rate for Payer: WPS Commercial |
$3,283.52
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 3 X 4HL RT 0.8 THICK TI 04.503.386
|
Facility
|
OP
|
$4,433.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,241.24 |
| Max. Negotiated Rate |
$17,732.00 |
| Rate for Payer: Aetna Commercial |
$3,989.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,812.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,241.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,881.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,216.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,127.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,349.49
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,078.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,480.71
|
| Rate for Payer: Health EOS Commercial |
$3,945.37
|
| Rate for Payer: HFN Commercial |
$4,078.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,324.75
|
| Rate for Payer: Multiplan Commercial |
$3,546.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,659.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,078.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,172.17
|
| Rate for Payer: Quartz Commercial |
$2,881.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,659.80
|
| Rate for Payer: The Alliance Commercial |
$17,732.00
|
| Rate for Payer: WEA Trust Commercial |
$2,438.15
|
| Rate for Payer: WPS Commercial |
$3,283.52
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 4 X 6HL RT 0.8 THICK TI 04.503.395
|
Facility
|
OP
|
$4,589.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226133
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,284.92 |
| Max. Negotiated Rate |
$18,356.00 |
| Rate for Payer: Aetna Commercial |
$4,130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,946.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,284.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,982.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,294.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,202.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,432.17
|
| Rate for Payer: Cash Price |
$1,376.70
|
| Rate for Payer: Cigna Commercial |
$4,221.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,568.00
|
| Rate for Payer: Health EOS Commercial |
$4,084.21
|
| Rate for Payer: HFN Commercial |
$4,221.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,441.75
|
| Rate for Payer: Multiplan Commercial |
$3,671.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,753.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,221.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,248.61
|
| Rate for Payer: Quartz Commercial |
$2,982.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,753.40
|
| Rate for Payer: The Alliance Commercial |
$18,356.00
|
| Rate for Payer: WEA Trust Commercial |
$2,523.95
|
| Rate for Payer: WPS Commercial |
$3,399.07
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 4 X 6HL RT 0.8 THICK TI 04.503.395
|
Facility
|
IP
|
$4,589.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226133
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,248.61 |
| Max. Negotiated Rate |
$4,221.88 |
| Rate for Payer: Aetna Commercial |
$4,130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,946.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,432.17
|
| Rate for Payer: Cash Price |
$1,376.70
|
| Rate for Payer: Cigna Commercial |
$4,221.88
|
| Rate for Payer: Health EOS Commercial |
$4,084.21
|
| Rate for Payer: HFN Commercial |
$4,221.88
|
| Rate for Payer: Multiplan Commercial |
$3,671.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,753.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,221.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,248.61
|
| Rate for Payer: Quartz Commercial |
$2,753.40
|
| Rate for Payer: WEA Trust Commercial |
$2,523.95
|
| Rate for Payer: WPS Commercial |
$3,399.07
|
|
|
L-PLATE MATRIX MIDFACE OBLIQUE 4 X 6HL RT TI 04.503.365
|
Facility
|
OP
|
$2,168.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.04 |
| Max. Negotiated Rate |
$8,672.00 |
| Rate for Payer: Aetna Commercial |
$1,951.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,864.48
|
| Rate for Payer: Aetna Managed Medicare |
$607.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,409.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,084.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.04
|
| Rate for Payer: Cash Price |
$650.40
|
| Rate for Payer: Cigna Commercial |
$1,994.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,213.21
|
| Rate for Payer: Health EOS Commercial |
$1,929.52
|
| Rate for Payer: HFN Commercial |
$1,994.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,626.00
|
| Rate for Payer: Multiplan Commercial |
$1,734.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,300.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,994.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,062.32
|
| Rate for Payer: Quartz Commercial |
$1,409.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,300.80
|
| Rate for Payer: The Alliance Commercial |
$8,672.00
|
| Rate for Payer: WEA Trust Commercial |
$1,192.40
|
| Rate for Payer: WPS Commercial |
$1,605.84
|
|
