|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
IP
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$147.49 |
| Max. Negotiated Rate |
$276.92 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$180.60
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
OP
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$1,204.00 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Aetna Managed Medicare |
$84.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$195.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.44
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.75
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$195.65
|
| Rate for Payer: Quartz Medicare Advantage |
$180.60
|
| Rate for Payer: The Alliance Commercial |
$1,204.00
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Professional
|
Both
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$132.44 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$285.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.60
|
| Rate for Payer: Health EOS Commercial |
$273.91
|
| Rate for Payer: HFN Commercial |
$285.95
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: Preferred Network Access Commercial |
$285.95
|
| Rate for Payer: Quartz Beloit One Network |
$132.44
|
| Rate for Payer: Quartz Commercial |
$171.57
|
| Rate for Payer: The Alliance Commercial |
$150.50
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1360828
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$172.92 |
| Max. Negotiated Rate |
$438.07 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.80
|
| Rate for Payer: Health EOS Commercial |
$357.63
|
| Rate for Payer: HFN Commercial |
$373.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: Preferred Network Access Commercial |
$373.35
|
| Rate for Payer: Quartz Beloit One Network |
$172.92
|
| Rate for Payer: Quartz Commercial |
$224.01
|
| Rate for Payer: The Alliance Commercial |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1360828
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1360828
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare PPO |
$294.75
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Professional
|
Both
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$143.44 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.60
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: HFN Commercial |
$309.70
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: The Alliance Commercial |
$163.00
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Facility
|
OP
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$91.28 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$91.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$211.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.43
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.50
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$195.60
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Facility
|
IP
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Professional
|
Both
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$132.44 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Aetna Commercial |
$285.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$285.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.60
|
| Rate for Payer: Health EOS Commercial |
$273.91
|
| Rate for Payer: HFN Commercial |
$285.95
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: Preferred Network Access Commercial |
$285.95
|
| Rate for Payer: Quartz Beloit One Network |
$132.44
|
| Rate for Payer: Quartz Commercial |
$171.57
|
| Rate for Payer: The Alliance Commercial |
$150.50
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
IP
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$147.49 |
| Max. Negotiated Rate |
$276.92 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$180.60
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
1360831
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$172.92 |
| Max. Negotiated Rate |
$438.07 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.80
|
| Rate for Payer: Health EOS Commercial |
$357.63
|
| Rate for Payer: HFN Commercial |
$373.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: Preferred Network Access Commercial |
$373.35
|
| Rate for Payer: Quartz Beloit One Network |
$172.92
|
| Rate for Payer: Quartz Commercial |
$224.01
|
| Rate for Payer: The Alliance Commercial |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
1360831
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare PPO |
$294.75
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
OP
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$1,204.00 |
| Rate for Payer: Aetna Commercial |
$270.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$258.86
|
| Rate for Payer: Aetna Managed Medicare |
$84.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$195.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.53
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$276.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.44
|
| Rate for Payer: Health EOS Commercial |
$267.89
|
| Rate for Payer: HFN Commercial |
$276.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$225.75
|
| Rate for Payer: Multiplan Commercial |
$240.80
|
| Rate for Payer: NAPHCARE Commercial |
$180.60
|
| Rate for Payer: Preferred Network Access Commercial |
$276.92
|
| Rate for Payer: Quartz Beloit One Network |
$147.49
|
| Rate for Payer: Quartz Commercial |
$195.65
|
| Rate for Payer: Quartz Medicare Advantage |
$180.60
|
| Rate for Payer: The Alliance Commercial |
$1,204.00
|
| Rate for Payer: WEA Trust Commercial |
$165.55
|
| Rate for Payer: WPS Commercial |
$222.95
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
1360831
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MANDIBLE/MAXILLA MUCOSAL SKIN GRAFTS
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960234
|
|
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
|
|
|
MANDIBLE/MAXILLA MUCOSAL SKIN GRAFTS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960234
|
|
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
|
|
|
MANDIBLE OSTEOTOMY
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2960293
|
|
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
|
|
|
MANDIBLE OSTEOTOMY
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2960293
|
|
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
|
|
|
MANDIBULAR RESECTION & RECONSTRUCTION
|
Facility
|
OP
|
$6,808.00
|
|
| Hospital Charge Code |
2960216
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,906.24 |
| Max. Negotiated Rate |
$27,232.00 |
| Rate for Payer: Aetna Commercial |
$6,127.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,854.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,906.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,425.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,404.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,267.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,608.24
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,263.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,809.76
|
| Rate for Payer: Health EOS Commercial |
$6,059.12
|
| Rate for Payer: HFN Commercial |
$6,263.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,106.00
|
| Rate for Payer: Multiplan Commercial |
$5,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,084.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,263.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,335.92
|
| Rate for Payer: Quartz Commercial |
$4,425.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,084.80
|
| Rate for Payer: The Alliance Commercial |
$27,232.00
|
| Rate for Payer: WEA Trust Commercial |
$3,744.40
|
| Rate for Payer: WPS Commercial |
$5,042.69
|
|
|
MANDIBULAR RESECTION & RECONSTRUCTION
|
Facility
|
IP
|
$6,808.00
|
|
| Hospital Charge Code |
2960216
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,335.92 |
| Max. Negotiated Rate |
$6,263.36 |
| Rate for Payer: Aetna Commercial |
$6,127.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,854.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,608.24
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,263.36
|
| Rate for Payer: Health EOS Commercial |
$6,059.12
|
| Rate for Payer: HFN Commercial |
$6,263.36
|
| Rate for Payer: Multiplan Commercial |
$5,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,084.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,263.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,335.92
|
| Rate for Payer: Quartz Commercial |
$4,084.80
|
| Rate for Payer: WEA Trust Commercial |
$3,744.40
|
| Rate for Payer: WPS Commercial |
$5,042.69
|
|
|
Manganese Level
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Manganese Level
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$26.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.24
|
| Rate for Payer: Anthem Medicaid |
$27.54
|
| Rate for Payer: Anthem Medicare Advantage |
$26.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.65
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$26.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Dean Health Medicaid |
$27.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$26.65
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$26.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$27.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.65
|
| Rate for Payer: Managed Health Services Medicaid |
$28.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$26.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$26.65
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$39.98
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$27.54
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$26.65
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: United Healthcare Medicaid |
$27.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.65
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: Wellcare Medicare |
$26.65
|
| Rate for Payer: WMAP Medicaid |
$27.54
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Manganese Level
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$94.07 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.80
|
| Rate for Payer: Health EOS Commercial |
$202.93
|
| Rate for Payer: HFN Commercial |
$211.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$94.07
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: Preferred Network Access Commercial |
$211.85
|
| Rate for Payer: Quartz Beloit One Network |
$98.12
|
| Rate for Payer: Quartz Commercial |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$111.50
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
MANIFOLD MEDIFOLD 3-PORT MX7083CV
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2969728
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
