|
LPE Interpretation
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 82664
|
| Hospital Charge Code |
2942942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
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 |
$751.88 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$751.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,745.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,342.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,288.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,502.72
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,013.96
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,611.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,745.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,611.17
|
| Rate for Payer: The Alliance Commercial |
$1,342.64
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
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 |
$1,315.79 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,611.17
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
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 |
$751.88 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Aetna Managed Medicare |
$751.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,745.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,342.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,288.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,502.72
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,013.96
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,611.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,745.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,611.17
|
| Rate for Payer: The Alliance Commercial |
$1,342.64
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
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 |
$1,315.79 |
| Max. Negotiated Rate |
$2,470.46 |
| Rate for Payer: Aetna Commercial |
$2,416.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,309.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,423.20
|
| Rate for Payer: Cash Price |
$774.60
|
| Rate for Payer: Cigna Commercial |
$2,470.46
|
| Rate for Payer: Health EOS Commercial |
$2,389.90
|
| Rate for Payer: HFN Commercial |
$2,470.46
|
| Rate for Payer: Multiplan Commercial |
$2,148.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,470.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,315.79
|
| Rate for Payer: Quartz Commercial |
$1,611.17
|
| Rate for Payer: WEA Trust Commercial |
$1,476.90
|
| Rate for Payer: WPS Commercial |
$1,988.91
|
|
|
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 |
$1,290.89 |
| Max. Negotiated Rate |
$4,241.49 |
| Rate for Payer: Aetna Commercial |
$4,149.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,964.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,290.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,996.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,305.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,212.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,443.47
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,241.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,580.01
|
| Rate for Payer: Health EOS Commercial |
$4,103.18
|
| Rate for Payer: HFN Commercial |
$4,241.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,457.74
|
| Rate for Payer: Multiplan Commercial |
$3,688.26
|
| Rate for Payer: NAPHCARE Commercial |
$2,766.19
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,259.06
|
| Rate for Payer: Quartz Commercial |
$2,996.71
|
| Rate for Payer: Quartz Medicare Advantage |
$2,766.19
|
| Rate for Payer: The Alliance Commercial |
$2,305.16
|
| Rate for Payer: WEA Trust Commercial |
$2,535.68
|
| Rate for Payer: WPS Commercial |
$3,414.74
|
|
|
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 |
$2,259.06 |
| Max. Negotiated Rate |
$4,241.49 |
| Rate for Payer: Aetna Commercial |
$4,149.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,964.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,443.47
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,241.49
|
| Rate for Payer: Health EOS Commercial |
$4,103.18
|
| Rate for Payer: HFN Commercial |
$4,241.49
|
| Rate for Payer: Multiplan Commercial |
$3,688.26
|
| Rate for Payer: Preferred Network Access Commercial |
$4,241.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,259.06
|
| Rate for Payer: Quartz Commercial |
$2,766.19
|
| Rate for Payer: WEA Trust Commercial |
$2,535.68
|
| Rate for Payer: WPS Commercial |
$3,414.74
|
|
|
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 |
$1,336.32 |
| Max. Negotiated Rate |
$4,390.76 |
| Rate for Payer: Aetna Commercial |
$4,295.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,104.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,336.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,102.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,386.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,290.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,529.46
|
| Rate for Payer: Cash Price |
$1,376.70
|
| Rate for Payer: Cigna Commercial |
$4,390.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,670.80
|
| Rate for Payer: Health EOS Commercial |
$4,247.58
|
| Rate for Payer: HFN Commercial |
$4,390.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,579.42
|
| Rate for Payer: Multiplan Commercial |
$3,818.05
|
| Rate for Payer: NAPHCARE Commercial |
$2,863.54
|
| Rate for Payer: Preferred Network Access Commercial |
$4,390.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,338.55
|
| Rate for Payer: Quartz Commercial |
$3,102.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2,863.54
|
| Rate for Payer: The Alliance Commercial |
$2,386.28
|
| Rate for Payer: WEA Trust Commercial |
$2,624.91
|
| Rate for Payer: WPS Commercial |
$3,534.91
|
|
|
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 |
$2,338.55 |
| Max. Negotiated Rate |
$4,390.76 |
| Rate for Payer: Aetna Commercial |
$4,295.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,104.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,529.46
|
| Rate for Payer: Cash Price |
$1,376.70
|
| Rate for Payer: Cigna Commercial |
$4,390.76
|
| Rate for Payer: Health EOS Commercial |
$4,247.58
|
| Rate for Payer: HFN Commercial |
$4,390.76
|
| Rate for Payer: Multiplan Commercial |
$3,818.05
|
| Rate for Payer: Preferred Network Access Commercial |
$4,390.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,338.55
|
| Rate for Payer: Quartz Commercial |
$2,863.54
|
| Rate for Payer: WEA Trust Commercial |
$2,624.91
|
| Rate for Payer: WPS Commercial |
$3,534.91
|
|
|
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 |
$1,104.81 |
| Max. Negotiated Rate |
$2,074.34 |
| Rate for Payer: Aetna Commercial |
$2,029.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.00
|
| Rate for Payer: Cash Price |
$650.40
|
| Rate for Payer: Cigna Commercial |
$2,074.34
|
| Rate for Payer: Health EOS Commercial |
$2,006.70
|
| Rate for Payer: HFN Commercial |
$2,074.34
|
| Rate for Payer: Multiplan Commercial |
$1,803.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.81
|
| Rate for Payer: Quartz Commercial |
$1,352.83
|
| Rate for Payer: WEA Trust Commercial |
$1,240.10
|
| Rate for Payer: WPS Commercial |
$1,670.01
|
|
|
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 |
$631.32 |
| Max. Negotiated Rate |
$2,074.34 |
| Rate for Payer: Aetna Commercial |
$2,029.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.06
|
| Rate for Payer: Aetna Managed Medicare |
$631.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,465.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,127.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,082.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.00
|
| Rate for Payer: Cash Price |
$650.40
|
| Rate for Payer: Cigna Commercial |
$2,074.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,261.78
|
| Rate for Payer: Health EOS Commercial |
$2,006.70
|
| Rate for Payer: HFN Commercial |
$2,074.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,691.04
|
| Rate for Payer: Multiplan Commercial |
$1,803.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,352.83
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.81
|
| Rate for Payer: Quartz Commercial |
$1,465.57
|
| Rate for Payer: Quartz Medicare Advantage |
$1,352.83
|
| Rate for Payer: The Alliance Commercial |
$1,127.36
|
| Rate for Payer: WEA Trust Commercial |
$1,240.10
|
| Rate for Payer: WPS Commercial |
$1,670.01
|
|
|
L pneumophila IgM / 30268
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
L pneumophila IgM / 30268
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$108.42
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
L pneumophila IgM / 30268
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
983199
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Aetna Commercial |
$137.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$137.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$131.55
|
| Rate for Payer: HFN Commercial |
$137.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$137.33
|
| Rate for Payer: Quartz Beloit One Network |
$63.61
|
| Rate for Payer: Quartz Commercial |
$82.40
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
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 |
$48.16 |
| Max. Negotiated Rate |
$450.53 |
| Rate for Payer: Aetna Commercial |
$450.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Medicare Advantage |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.16
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$450.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$237.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.16
|
| Rate for Payer: Health EOS Commercial |
$431.56
|
| Rate for Payer: HFN Commercial |
$450.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$170.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$170.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.16
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: NAPHCARE Commercial |
$72.24
|
| Rate for Payer: Preferred Network Access Commercial |
$450.53
|
| Rate for Payer: Quartz Beloit One Network |
$208.67
|
| Rate for Payer: Quartz Commercial |
$270.32
|
| Rate for Payer: Quartz Medicare Advantage |
$48.16
|
| Rate for Payer: The Alliance Commercial |
$190.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.16
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$211.91
|
|
|
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 |
$232.38 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$284.54
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
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 |
$48.16 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.95
|
| Rate for Payer: Anthem Medicare Advantage |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.16
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$48.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$48.16
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$179.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$48.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$48.16
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: NAPHCARE Commercial |
$72.24
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$308.26
|
| Rate for Payer: Quartz Medicare Advantage |
$48.16
|
| Rate for Payer: The Alliance Commercial |
$192.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.16
|
| Rate for Payer: United Healthcare PPO |
$355.68
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: Wellcare Medicare |
$48.16
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
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 |
$17.33 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$21.22
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
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 |
$9.90 |
| Max. Negotiated Rate |
$32.53 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.74
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$32.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.79
|
| Rate for Payer: Health EOS Commercial |
$31.47
|
| Rate for Payer: HFN Commercial |
$32.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$32.53
|
| Rate for Payer: Quartz Beloit One Network |
$17.33
|
| Rate for Payer: Quartz Commercial |
$22.98
|
| Rate for Payer: Quartz Medicare Advantage |
$21.22
|
| Rate for Payer: The Alliance Commercial |
$10.40
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$26.19
|
|
|
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 |
$2.60 |
| Max. Negotiated Rate |
$33.59 |
| Rate for Payer: Aetna Commercial |
$33.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.41
|
| Rate for Payer: Aetna Managed Medicare |
$2.60
|
| Rate for Payer: Anthem Medicare Advantage |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$33.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.60
|
| Rate for Payer: Health EOS Commercial |
$32.18
|
| Rate for Payer: HFN Commercial |
$33.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$28.29
|
| Rate for Payer: NAPHCARE Commercial |
$3.90
|
| Rate for Payer: Preferred Network Access Commercial |
$33.59
|
| Rate for Payer: Quartz Beloit One Network |
$15.56
|
| Rate for Payer: Quartz Commercial |
$20.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2.60
|
| Rate for Payer: The Alliance Commercial |
$7.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$19.45
|
| Rate for Payer: WPS Commercial |
$4.55
|
|
|
LUBRICANT ROTAGUIDE 23548-001
|
Facility
|
IP
|
$1,536.00
|
|
| Hospital Charge Code |
3609505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$782.75 |
| Max. Negotiated Rate |
$1,469.64 |
| Rate for Payer: Aetna Commercial |
$1,437.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,373.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.64
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cigna Commercial |
$1,469.64
|
| Rate for Payer: Health EOS Commercial |
$1,421.72
|
| Rate for Payer: HFN Commercial |
$1,469.64
|
| Rate for Payer: Multiplan Commercial |
$1,277.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,469.64
|
| Rate for Payer: Quartz Beloit One Network |
$782.75
|
| Rate for Payer: Quartz Commercial |
$958.46
|
| Rate for Payer: WEA Trust Commercial |
$878.59
|
| Rate for Payer: WPS Commercial |
$1,183.18
|
|
|
LUBRICANT ROTAGUIDE 23548-001
|
Facility
|
OP
|
$1,536.00
|
|
| Hospital Charge Code |
3609505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$447.28 |
| Max. Negotiated Rate |
$1,469.64 |
| Rate for Payer: Aetna Commercial |
$1,437.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,373.80
|
| Rate for Payer: Aetna Managed Medicare |
$447.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,038.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$798.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$766.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.64
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cigna Commercial |
$1,469.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$893.95
|
| Rate for Payer: Health EOS Commercial |
$1,421.72
|
| Rate for Payer: HFN Commercial |
$1,469.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,198.08
|
| Rate for Payer: Multiplan Commercial |
$1,277.95
|
| Rate for Payer: NAPHCARE Commercial |
$958.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,469.64
|
| Rate for Payer: Quartz Beloit One Network |
$782.75
|
| Rate for Payer: Quartz Commercial |
$1,038.34
|
| Rate for Payer: Quartz Medicare Advantage |
$958.46
|
| Rate for Payer: The Alliance Commercial |
$798.72
|
| Rate for Payer: WEA Trust Commercial |
$878.59
|
| Rate for Payer: WPS Commercial |
$1,183.18
|
|
|
LUBRICATING DEODORANT ADAPT
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974310
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
LUBRICATING DEODORANT ADAPT
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974310
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
LUEKOTAPE 1-1/2 X 15 YDS #576168
|
Facility
|
OP
|
$148.00
|
|
| Hospital Charge Code |
2969565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$43.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.14
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.44
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$100.05
|
| Rate for Payer: Quartz Medicare Advantage |
$92.35
|
| Rate for Payer: The Alliance Commercial |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
