|
L-PLATE MATRIX MIDFACE OBLIQUE 4 X 6HL RT TI 04.503.365
|
Facility
|
IP
|
$2,168.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349173
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,062.32 |
| Max. Negotiated Rate |
$1,994.56 |
| Rate for Payer: Aetna Commercial |
$1,951.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,864.48
|
| 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: Health EOS Commercial |
$1,929.52
|
| Rate for Payer: HFN Commercial |
$1,994.56
|
| 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 |
$1,300.80
|
| Rate for Payer: WEA Trust Commercial |
$1,192.40
|
| Rate for Payer: WPS Commercial |
$1,605.84
|
|
|
L pneumophila IgM / 30268
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.01 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$132.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.40
|
| Rate for Payer: Health EOS Commercial |
$126.49
|
| Rate for Payer: HFN Commercial |
$132.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.01
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: Preferred Network Access Commercial |
$132.05
|
| Rate for Payer: Quartz Beloit One Network |
$61.16
|
| Rate for Payer: Quartz Commercial |
$79.23
|
| Rate for Payer: The Alliance Commercial |
$69.50
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
L pneumophila IgM / 30268
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.40
|
| Rate for Payer: Anthem Medicaid |
$15.81
|
| Rate for Payer: Anthem Medicare Advantage |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.30
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Dean Health Medicaid |
$15.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.30
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.30
|
| Rate for Payer: Managed Health Services Medicaid |
$16.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.30
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.95
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.81
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$15.30
|
| Rate for Payer: The Alliance Commercial |
$61.20
|
| Rate for Payer: United Healthcare Medicaid |
$15.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.30
|
| Rate for Payer: United Healthcare PPO |
$104.25
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: Wellcare Medicare |
$15.30
|
| Rate for Payer: WMAP Medicaid |
$15.81
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
L pneumophila IgM / 30268
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Lp-PLA2 (Lipoprotein-Associated Phospholipase A2)
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
CPT 83698
|
| Hospital Charge Code |
983307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.31 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$46.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$173.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.87
|
| Rate for Payer: Anthem Medicaid |
$47.73
|
| Rate for Payer: Anthem Medicare Advantage |
$46.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.31
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.18
|
| Rate for Payer: Dean Health Medicaid |
$47.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.31
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$172.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.31
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$47.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.31
|
| Rate for Payer: Managed Health Services Medicaid |
$49.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.31
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$69.46
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$47.73
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$46.31
|
| Rate for Payer: The Alliance Commercial |
$185.24
|
| Rate for Payer: United Healthcare Medicaid |
$47.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.31
|
| Rate for Payer: United Healthcare PPO |
$342.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: Wellcare Medicare |
$46.31
|
| Rate for Payer: WMAP Medicaid |
$47.73
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
Lp-PLA2 (Lipoprotein-Associated Phospholipase A2)
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
CPT 83698
|
| Hospital Charge Code |
983307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
Lp-PLA2 (Lipoprotein-Associated Phospholipase A2)
|
Professional
|
Both
|
$456.00
|
|
|
Service Code
|
CPT 83698
|
| Hospital Charge Code |
983307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$163.47 |
| Max. Negotiated Rate |
$433.20 |
| Rate for Payer: Aetna Commercial |
$433.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$433.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$228.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.60
|
| Rate for Payer: Health EOS Commercial |
$414.96
|
| Rate for Payer: HFN Commercial |
$433.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$163.47
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: Preferred Network Access Commercial |
$433.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.64
|
| Rate for Payer: Quartz Commercial |
$259.92
|
| Rate for Payer: The Alliance Commercial |
$228.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
Lt Compres band >=5/yd A6450"
|
Professional
|
Both
|
$34.00
|
|
|
Service Code
|
HCPCS A6450
|
| Hospital Charge Code |
4586629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: Aetna Commercial |
$32.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.40
|
| Rate for Payer: Health EOS Commercial |
$30.94
|
| Rate for Payer: HFN Commercial |
$32.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: Preferred Network Access Commercial |
$32.30
|
| Rate for Payer: Quartz Beloit One Network |
$14.96
|
| Rate for Payer: Quartz Commercial |
$19.38
|
| Rate for Payer: The Alliance Commercial |
$17.00
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
Lt Compres band >=5/yd A6450"
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS A6450
|
| Hospital Charge Code |
4586629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Aetna Managed Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.03
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.50
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$22.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20.40
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
Lt Compres band >=5/yd A6450"
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS A6450
|
| Hospital Charge Code |
4586629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
LUBRICANT ROTAGUIDE 23548-001
|
Facility
|
OP
|
$1,536.00
|
|
| Hospital Charge Code |
3609505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$430.08 |
| Max. Negotiated Rate |
$6,144.00 |
| Rate for Payer: Aetna Commercial |
$1,382.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.96
|
| Rate for Payer: Aetna Managed Medicare |
$430.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$998.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$768.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$737.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$814.08
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cigna Commercial |
$1,413.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$859.55
|
| Rate for Payer: Health EOS Commercial |
$1,367.04
|
| Rate for Payer: HFN Commercial |
$1,413.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,152.00
|
| Rate for Payer: Multiplan Commercial |
$1,228.80
|
| Rate for Payer: NAPHCARE Commercial |
$921.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,413.12
|
| Rate for Payer: Quartz Beloit One Network |
$752.64
|
| Rate for Payer: Quartz Commercial |
$998.40
|
| Rate for Payer: Quartz Medicare Advantage |
$921.60
|
| Rate for Payer: The Alliance Commercial |
$6,144.00
|
| Rate for Payer: WEA Trust Commercial |
$844.80
|
| Rate for Payer: WPS Commercial |
$1,137.72
|
|
|
LUBRICANT ROTAGUIDE 23548-001
|
Facility
|
IP
|
$1,536.00
|
|
| Hospital Charge Code |
3609505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$752.64 |
| Max. Negotiated Rate |
$1,413.12 |
| Rate for Payer: Aetna Commercial |
$1,382.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$814.08
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cigna Commercial |
$1,413.12
|
| Rate for Payer: Health EOS Commercial |
$1,367.04
|
| Rate for Payer: HFN Commercial |
$1,413.12
|
| Rate for Payer: Multiplan Commercial |
$1,228.80
|
| Rate for Payer: NAPHCARE Commercial |
$921.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,413.12
|
| Rate for Payer: Quartz Beloit One Network |
$752.64
|
| Rate for Payer: Quartz Commercial |
$921.60
|
| Rate for Payer: WEA Trust Commercial |
$844.80
|
| Rate for Payer: WPS Commercial |
$1,137.72
|
|
|
LUBRICATING DEODORANT ADAPT
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974310
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
LUBRICATING DEODORANT ADAPT
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974310
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
LUEKOTAPE 1-1/2 X 15 YDS #576168
|
Facility
|
OP
|
$148.00
|
|
| Hospital Charge Code |
2969565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$592.00 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$41.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.82
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.00
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$96.20
|
| Rate for Payer: Quartz Medicare Advantage |
$88.80
|
| Rate for Payer: The Alliance Commercial |
$592.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
LUEKOTAPE 1-1/2 X 15 YDS #576168
|
Facility
|
IP
|
$148.00
|
|
| Hospital Charge Code |
2969565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$72.52 |
| Max. Negotiated Rate |
$136.16 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$88.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
LUGOL'S Potassium-Iodine 10% Iodine 5% Purified Water 1Fl oz (MED)
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
4201305
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
LUGOL'S Potassium-Iodine 10% Iodine 5% Purified Water 1Fl oz (MED)
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
4201305
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
LUMBAR ARTHRODESIS
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2959821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,118.76 |
| Max. Negotiated Rate |
$3,978.08 |
| Rate for Payer: Aetna Commercial |
$3,891.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$3,978.08
|
| Rate for Payer: Health EOS Commercial |
$3,848.36
|
| Rate for Payer: HFN Commercial |
$3,978.08
|
| Rate for Payer: Multiplan Commercial |
$3,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
| Rate for Payer: Quartz Commercial |
$2,594.40
|
| Rate for Payer: WEA Trust Commercial |
$2,378.20
|
| Rate for Payer: WPS Commercial |
$3,202.79
|
|
|
LUMBAR ARTHRODESIS
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2959821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,210.72 |
| Max. Negotiated Rate |
$17,296.00 |
| Rate for Payer: Aetna Commercial |
$3,891.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,210.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,810.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,162.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,075.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$3,978.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,419.71
|
| Rate for Payer: Health EOS Commercial |
$3,848.36
|
| Rate for Payer: HFN Commercial |
$3,978.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,243.00
|
| Rate for Payer: Multiplan Commercial |
$3,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
| Rate for Payer: Quartz Commercial |
$2,810.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,594.40
|
| Rate for Payer: The Alliance Commercial |
$17,296.00
|
| Rate for Payer: WEA Trust Commercial |
$2,378.20
|
| Rate for Payer: WPS Commercial |
$3,202.79
|
|
|
LUMBAR PUNCTURE, SPINAL
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960210
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
LUMBAR PUNCTURE, SPINAL
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960210
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
LUMBAR PUNCTURE W/FLUORO OR CT 62328
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 62328
|
| Hospital Charge Code |
5569369
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$200.49 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$200.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$304.80
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: HFN Commercial |
$482.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$293.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$293.41
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: The Alliance Commercial |
$254.00
|
| Rate for Payer: United Healthcare Medicaid |
$200.49
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$376.28
|
|
|
LUMBAR SYMPATHECTOMY
|
Facility
|
OP
|
$7,388.00
|
|
| Hospital Charge Code |
2960398
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.64 |
| Max. Negotiated Rate |
$29,552.00 |
| Rate for Payer: Aetna Commercial |
$6,649.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,353.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,068.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,802.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,694.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,546.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,915.64
|
| Rate for Payer: Cash Price |
$2,216.40
|
| Rate for Payer: Cigna Commercial |
$6,796.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,134.32
|
| Rate for Payer: Health EOS Commercial |
$6,575.32
|
| Rate for Payer: HFN Commercial |
$6,796.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,541.00
|
| Rate for Payer: Multiplan Commercial |
$5,910.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,432.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,796.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,620.12
|
| Rate for Payer: Quartz Commercial |
$4,802.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,432.80
|
| Rate for Payer: The Alliance Commercial |
$29,552.00
|
| Rate for Payer: WEA Trust Commercial |
$4,063.40
|
| Rate for Payer: WPS Commercial |
$5,472.29
|
|
|
LUMBAR SYMPATHECTOMY
|
Facility
|
IP
|
$7,388.00
|
|
| Hospital Charge Code |
2960398
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,620.12 |
| Max. Negotiated Rate |
$6,796.96 |
| Rate for Payer: Aetna Commercial |
$6,649.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,353.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,915.64
|
| Rate for Payer: Cash Price |
$2,216.40
|
| Rate for Payer: Cigna Commercial |
$6,796.96
|
| Rate for Payer: Health EOS Commercial |
$6,575.32
|
| Rate for Payer: HFN Commercial |
$6,796.96
|
| Rate for Payer: Multiplan Commercial |
$5,910.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,432.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,796.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,620.12
|
| Rate for Payer: Quartz Commercial |
$4,432.80
|
| Rate for Payer: WEA Trust Commercial |
$4,063.40
|
| Rate for Payer: WPS Commercial |
$5,472.29
|
|
