|
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 |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
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 |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: United Healthcare PPO |
$306.54
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Professional
|
Both
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$149.18 |
| Max. Negotiated Rate |
$322.09 |
| Rate for Payer: Aetna Commercial |
$322.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$322.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$169.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.42
|
| Rate for Payer: Health EOS Commercial |
$308.53
|
| Rate for Payer: HFN Commercial |
$322.09
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$322.09
|
| Rate for Payer: Quartz Beloit One Network |
$149.18
|
| Rate for Payer: Quartz Commercial |
$193.25
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Facility
|
OP
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$94.93 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Aetna Managed Medicare |
$94.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$220.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.73
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.28
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: NAPHCARE Commercial |
$203.42
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$220.38
|
| Rate for Payer: Quartz Medicare Advantage |
$203.42
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: United Healthcare PPO |
$254.28
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
MA Mammogram Digital WWHSP Diag Right
|
Facility
|
IP
|
$326.00
|
|
| Hospital Charge Code |
2980126
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$166.13 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$203.42
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
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 |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: United Healthcare PPO |
$306.54
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
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 |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
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 |
$179.84 |
| Max. Negotiated Rate |
$455.59 |
| Rate for Payer: Aetna Commercial |
$388.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| 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 |
$388.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.23
|
| Rate for Payer: Health EOS Commercial |
$371.94
|
| Rate for Payer: HFN Commercial |
$388.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$455.59
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$388.28
|
| Rate for Payer: Quartz Beloit One Network |
$179.84
|
| Rate for Payer: Quartz Commercial |
$232.97
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
IP
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$153.39 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$187.82
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Professional
|
Both
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$137.74 |
| Max. Negotiated Rate |
$297.39 |
| Rate for Payer: Aetna Commercial |
$297.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$297.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.82
|
| Rate for Payer: Health EOS Commercial |
$284.87
|
| Rate for Payer: HFN Commercial |
$297.39
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$297.39
|
| Rate for Payer: Quartz Beloit One Network |
$137.74
|
| Rate for Payer: Quartz Commercial |
$178.43
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MA Mammogram Digital WWHSP Diag RT
|
Facility
|
OP
|
$301.00
|
|
| Hospital Charge Code |
1360802
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Aetna Managed Medicare |
$87.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$203.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.18
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.78
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: NAPHCARE Commercial |
$187.82
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$203.48
|
| Rate for Payer: Quartz Medicare Advantage |
$187.82
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MAMMOGRAPHY & OTHER RELATED PROCEDURES
|
Facility
|
OP
|
$87.79
|
|
|
Service Code
|
EAPG 00286
|
| Min. Negotiated Rate |
$84.41 |
| Max. Negotiated Rate |
$87.79 |
| Rate for Payer: Anthem Medicaid |
$84.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$84.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.41
|
| Rate for Payer: Dean Health Medicaid |
$84.41
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$84.41
|
| Rate for Payer: Managed Health Services Medicaid |
$87.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.41
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$84.41
|
| Rate for Payer: United Healthcare Medicaid |
$84.41
|
|
|
MANDIBLE/MAXILLA MUCOSAL SKIN GRAFTS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960234
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
MANDIBLE/MAXILLA MUCOSAL SKIN GRAFTS
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960234
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
MANDIBLE OSTEOTOMY
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2960293
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,259.15 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,259.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,923.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,248.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,158.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,516.57
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,372.72
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,698.18
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,923.02
|
| Rate for Payer: Quartz Medicare Advantage |
$2,698.18
|
| Rate for Payer: The Alliance Commercial |
$2,248.48
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
MANDIBLE OSTEOTOMY
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2960293
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,203.51 |
| Max. Negotiated Rate |
$4,137.20 |
| Rate for Payer: Aetna Commercial |
$4,047.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,867.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,383.39
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$4,137.20
|
| Rate for Payer: Health EOS Commercial |
$4,002.29
|
| Rate for Payer: HFN Commercial |
$4,137.20
|
| Rate for Payer: Multiplan Commercial |
$3,597.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,137.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,203.51
|
| Rate for Payer: Quartz Commercial |
$2,698.18
|
| Rate for Payer: WEA Trust Commercial |
$2,473.33
|
| Rate for Payer: WPS Commercial |
$3,330.78
|
|
|
MANDIBULAR RESECTION & RECONSTRUCTION
|
Facility
|
IP
|
$6,808.00
|
|
| Hospital Charge Code |
2960216
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,469.36 |
| Max. Negotiated Rate |
$6,513.89 |
| Rate for Payer: Aetna Commercial |
$6,372.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,089.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,513.89
|
| Rate for Payer: Health EOS Commercial |
$6,301.48
|
| Rate for Payer: HFN Commercial |
$6,513.89
|
| Rate for Payer: Multiplan Commercial |
$5,664.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,513.89
|
| Rate for Payer: Quartz Beloit One Network |
$3,469.36
|
| Rate for Payer: Quartz Commercial |
$4,248.19
|
| Rate for Payer: WEA Trust Commercial |
$3,894.18
|
| Rate for Payer: WPS Commercial |
$5,244.20
|
|
|
MANDIBULAR RESECTION & RECONSTRUCTION
|
Facility
|
OP
|
$6,808.00
|
|
| Hospital Charge Code |
2960216
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,982.49 |
| Max. Negotiated Rate |
$6,513.89 |
| Rate for Payer: Aetna Commercial |
$6,372.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,089.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,982.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,602.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,540.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,398.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,513.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,962.26
|
| Rate for Payer: Health EOS Commercial |
$6,301.48
|
| Rate for Payer: HFN Commercial |
$6,513.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,310.24
|
| Rate for Payer: Multiplan Commercial |
$5,664.26
|
| Rate for Payer: NAPHCARE Commercial |
$4,248.19
|
| Rate for Payer: Preferred Network Access Commercial |
$6,513.89
|
| Rate for Payer: Quartz Beloit One Network |
$3,469.36
|
| Rate for Payer: Quartz Commercial |
$4,602.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,248.19
|
| Rate for Payer: The Alliance Commercial |
$3,540.16
|
| Rate for Payer: WEA Trust Commercial |
$3,894.18
|
| Rate for Payer: WPS Commercial |
$5,244.20
|
|
|
Manganese Level
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Manganese Level
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$220.32 |
| Rate for Payer: Aetna Commercial |
$220.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$27.72
|
| Rate for Payer: Anthem Medicare Advantage |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.72
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$220.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$115.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.72
|
| Rate for Payer: Health EOS Commercial |
$211.05
|
| Rate for Payer: HFN Commercial |
$220.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.72
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$41.57
|
| Rate for Payer: Preferred Network Access Commercial |
$220.32
|
| Rate for Payer: Quartz Beloit One Network |
$102.04
|
| Rate for Payer: Quartz Commercial |
$132.19
|
| Rate for Payer: Quartz Medicare Advantage |
$27.72
|
| Rate for Payer: The Alliance Commercial |
$109.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.72
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$121.95
|
|
|
Manganese Level
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 83785
|
| Hospital Charge Code |
978012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$27.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.01
|
| Rate for Payer: Anthem Medicare Advantage |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.72
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27.72
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27.72
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$41.57
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$27.72
|
| Rate for Payer: The Alliance Commercial |
$110.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.72
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$27.72
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
MANIFOLD MEDIFOLD 3-PORT MX7083CV
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2969728
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
MANIFOLD MEDIFOLD 3-PORT MX7083CV
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2969728
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$35.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.94
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$76.75
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$76.75
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
MANIFOLD NEPTUNE 4 PORT 0700-040-000
|
Facility
|
IP
|
$460.00
|
|
| Hospital Charge Code |
2966091
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$234.42 |
| Max. Negotiated Rate |
$440.13 |
| Rate for Payer: Aetna Commercial |
$430.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.55
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$440.13
|
| Rate for Payer: Health EOS Commercial |
$425.78
|
| Rate for Payer: HFN Commercial |
$440.13
|
| Rate for Payer: Multiplan Commercial |
$382.72
|
| Rate for Payer: Preferred Network Access Commercial |
$440.13
|
| Rate for Payer: Quartz Beloit One Network |
$234.42
|
| Rate for Payer: Quartz Commercial |
$287.04
|
| Rate for Payer: WEA Trust Commercial |
$263.12
|
| Rate for Payer: WPS Commercial |
$354.34
|
|
|
MANIFOLD NEPTUNE 4 PORT 0700-040-000
|
Facility
|
OP
|
$460.00
|
|
| Hospital Charge Code |
2966091
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.95 |
| Max. Negotiated Rate |
$440.13 |
| Rate for Payer: Aetna Commercial |
$430.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.42
|
| Rate for Payer: Aetna Managed Medicare |
$133.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.55
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$440.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$425.78
|
| Rate for Payer: HFN Commercial |
$440.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$382.72
|
| Rate for Payer: NAPHCARE Commercial |
$287.04
|
| Rate for Payer: Preferred Network Access Commercial |
$440.13
|
| Rate for Payer: Quartz Beloit One Network |
$234.42
|
| Rate for Payer: Quartz Commercial |
$310.96
|
| Rate for Payer: Quartz Medicare Advantage |
$287.04
|
| Rate for Payer: The Alliance Commercial |
$239.20
|
| Rate for Payer: WEA Trust Commercial |
$263.12
|
| Rate for Payer: WPS Commercial |
$354.34
|
|
