|
Maverick 4.0mm x 15mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Maverick 4.0m x 9mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Maverick 4.0m x 9mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Maverick 4.0m x 9mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: HFN Commercial |
$1,808.80
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
MAXILLARY ANTROSTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2959806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
MAXILLARY ANTROSTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2959806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
MAXILLARY & MANDIBULAR VESTIBULOPLASTY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960504
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
MAXILLARY & MANDIBULAR VESTIBULOPLASTY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960504
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
MAXILLA, TUMOR RESECTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960456
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
MAXILLA, TUMOR RESECTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960456
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
Maximum Voluntary Ventilation - Pulmonary Function Test Charge
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
3006994
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$188.65 |
| Max. Negotiated Rate |
$354.20 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$231.00
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$231.00
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Maximum Voluntary Ventilation - Pulmonary Function Test Charge
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
3006994
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$354.20 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$331.10
|
| Rate for Payer: Aetna Managed Medicare |
$60.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.80
|
| Rate for Payer: Anthem Medicare Advantage |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$204.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.46
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$354.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$60.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$60.46
|
| Rate for Payer: Health EOS Commercial |
$342.65
|
| Rate for Payer: HFN Commercial |
$354.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$60.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$60.46
|
| Rate for Payer: Multiplan Commercial |
$308.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.69
|
| Rate for Payer: Preferred Network Access Commercial |
$354.20
|
| Rate for Payer: Quartz Beloit One Network |
$188.65
|
| Rate for Payer: Quartz Commercial |
$250.25
|
| Rate for Payer: Quartz Medicare Advantage |
$60.46
|
| Rate for Payer: The Alliance Commercial |
$241.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.46
|
| Rate for Payer: United Healthcare PPO |
$288.75
|
| Rate for Payer: WEA Trust Commercial |
$211.75
|
| Rate for Payer: Wellcare Medicare |
$60.46
|
| Rate for Payer: WPS Commercial |
$285.17
|
|
|
Mayo, Antibody Stain
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.16 |
| Max. Negotiated Rate |
$1,388.00 |
| Rate for Payer: Aetna Commercial |
$312.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.42
|
| Rate for Payer: Aetna Managed Medicare |
$97.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$166.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.91
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$319.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.18
|
| Rate for Payer: Health EOS Commercial |
$308.83
|
| Rate for Payer: HFN Commercial |
$319.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$277.60
|
| Rate for Payer: NAPHCARE Commercial |
$208.20
|
| Rate for Payer: Preferred Network Access Commercial |
$319.24
|
| Rate for Payer: Quartz Beloit One Network |
$170.03
|
| Rate for Payer: Quartz Commercial |
$225.55
|
| Rate for Payer: Quartz Medicare Advantage |
$208.20
|
| Rate for Payer: The Alliance Commercial |
$1,388.00
|
| Rate for Payer: United Healthcare PPO |
$260.25
|
| Rate for Payer: WEA Trust Commercial |
$190.85
|
| Rate for Payer: WPS Commercial |
$257.02
|
|
|
Mayo, Antibody Stain
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$170.03 |
| Max. Negotiated Rate |
$319.24 |
| Rate for Payer: Aetna Commercial |
$312.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.91
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$319.24
|
| Rate for Payer: Health EOS Commercial |
$308.83
|
| Rate for Payer: HFN Commercial |
$319.24
|
| Rate for Payer: Multiplan Commercial |
$277.60
|
| Rate for Payer: NAPHCARE Commercial |
$208.20
|
| Rate for Payer: Preferred Network Access Commercial |
$319.24
|
| Rate for Payer: Quartz Beloit One Network |
$170.03
|
| Rate for Payer: Quartz Commercial |
$208.20
|
| Rate for Payer: WEA Trust Commercial |
$190.85
|
| Rate for Payer: WPS Commercial |
$257.02
|
|
|
Mayo, Antibody Stain
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$329.65 |
| Rate for Payer: Aetna Commercial |
$329.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$298.42
|
| Rate for Payer: Anthem Commercial |
$17.11
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$329.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$173.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$208.20
|
| Rate for Payer: Health EOS Commercial |
$315.77
|
| Rate for Payer: HFN Commercial |
$329.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$315.33
|
| Rate for Payer: Multiplan Commercial |
$277.60
|
| Rate for Payer: Preferred Network Access Commercial |
$329.65
|
| Rate for Payer: Quartz Beloit One Network |
$152.68
|
| Rate for Payer: Quartz Commercial |
$197.79
|
| Rate for Payer: The Alliance Commercial |
$173.50
|
| Rate for Payer: WEA Trust Commercial |
$190.85
|
| Rate for Payer: WPS Commercial |
$257.02
|
|
|
Mayo Consult, Outside Slide
|
Professional
|
Both
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$334.01 |
| Max. Negotiated Rate |
$752.40 |
| Rate for Payer: Aetna Commercial |
$752.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$752.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$396.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.20
|
| Rate for Payer: Health EOS Commercial |
$720.72
|
| Rate for Payer: HFN Commercial |
$752.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$334.01
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: Preferred Network Access Commercial |
$752.40
|
| Rate for Payer: Quartz Beloit One Network |
$348.48
|
| Rate for Payer: Quartz Commercial |
$451.44
|
| Rate for Payer: The Alliance Commercial |
$396.00
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
Mayo Consult, Outside Slide
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$388.08 |
| Max. Negotiated Rate |
$728.64 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$475.20
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
Mayo Consult, Outside Slide
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$728.64 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.80
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$443.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$514.80
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: The Alliance Commercial |
$158.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$594.00
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
Mayo Consult, w/ History Review
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 88325
|
| Hospital Charge Code |
4574688
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$168.82 |
| Max. Negotiated Rate |
$728.64 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$443.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$514.80
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$594.00
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
Mayo Consult, w/ History Review
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 88325
|
| Hospital Charge Code |
4574688
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$388.08 |
| Max. Negotiated Rate |
$728.64 |
| Rate for Payer: Aetna Commercial |
$712.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$681.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$419.76
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$728.64
|
| Rate for Payer: Health EOS Commercial |
$704.88
|
| Rate for Payer: HFN Commercial |
$728.64
|
| Rate for Payer: Multiplan Commercial |
$633.60
|
| Rate for Payer: NAPHCARE Commercial |
$475.20
|
| Rate for Payer: Preferred Network Access Commercial |
$728.64
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$475.20
|
| Rate for Payer: WEA Trust Commercial |
$435.60
|
| Rate for Payer: WPS Commercial |
$586.63
|
|
|
Mayo Consult, w/Slide Prep
|
Facility
|
OP
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.56 |
| Max. Negotiated Rate |
$757.16 |
| Rate for Payer: Aetna Commercial |
$740.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.91
|
| Rate for Payer: Anthem Medicare Advantage |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.56
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$757.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.56
|
| Rate for Payer: Health EOS Commercial |
$732.47
|
| Rate for Payer: HFN Commercial |
$757.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$658.40
|
| Rate for Payer: NAPHCARE Commercial |
$80.34
|
| Rate for Payer: Preferred Network Access Commercial |
$757.16
|
| Rate for Payer: Quartz Beloit One Network |
$403.27
|
| Rate for Payer: Quartz Commercial |
$534.95
|
| Rate for Payer: Quartz Medicare Advantage |
$53.56
|
| Rate for Payer: The Alliance Commercial |
$214.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.56
|
| Rate for Payer: United Healthcare PPO |
$617.25
|
| Rate for Payer: WEA Trust Commercial |
$452.65
|
| Rate for Payer: Wellcare Medicare |
$53.56
|
| Rate for Payer: WPS Commercial |
$609.60
|
|
|
Mayo Consult, w/Slide Prep
|
Facility
|
IP
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$403.27 |
| Max. Negotiated Rate |
$757.16 |
| Rate for Payer: Aetna Commercial |
$740.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.19
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$757.16
|
| Rate for Payer: Health EOS Commercial |
$732.47
|
| Rate for Payer: HFN Commercial |
$757.16
|
| Rate for Payer: Multiplan Commercial |
$658.40
|
| Rate for Payer: NAPHCARE Commercial |
$493.80
|
| Rate for Payer: Preferred Network Access Commercial |
$757.16
|
| Rate for Payer: Quartz Beloit One Network |
$403.27
|
| Rate for Payer: Quartz Commercial |
$493.80
|
| Rate for Payer: WEA Trust Commercial |
$452.65
|
| Rate for Payer: WPS Commercial |
$609.60
|
|
|
Mayo Consult, w/Slide Prep
|
Professional
|
Both
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.35 |
| Max. Negotiated Rate |
$781.85 |
| Rate for Payer: Aetna Commercial |
$781.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.78
|
| Rate for Payer: Anthem Commercial |
$73.35
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$781.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$411.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$493.80
|
| Rate for Payer: Health EOS Commercial |
$748.93
|
| Rate for Payer: HFN Commercial |
$781.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$392.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$392.43
|
| Rate for Payer: Multiplan Commercial |
$658.40
|
| Rate for Payer: Preferred Network Access Commercial |
$781.85
|
| Rate for Payer: Quartz Beloit One Network |
$362.12
|
| Rate for Payer: Quartz Commercial |
$469.11
|
| Rate for Payer: The Alliance Commercial |
$411.50
|
| Rate for Payer: WEA Trust Commercial |
$452.65
|
| Rate for Payer: WPS Commercial |
$609.60
|
|
|
Mayo, Copper Liver Ts
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
4860606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.41 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$12.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.60
|
| Rate for Payer: Anthem Medicaid |
$12.82
|
| Rate for Payer: Anthem Medicare Advantage |
$12.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.41
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Dean Health Medicaid |
$12.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.41
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.41
|
| Rate for Payer: Managed Health Services Medicaid |
$13.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.41
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.62
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.82
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$12.41
|
| Rate for Payer: The Alliance Commercial |
$49.64
|
| Rate for Payer: United Healthcare Medicaid |
$12.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.41
|
| Rate for Payer: United Healthcare PPO |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: Wellcare Medicare |
$12.41
|
| Rate for Payer: WMAP Medicaid |
$12.82
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Mayo, Copper Liver Ts
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
4860606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
