|
Maverick 4.0mm x 15mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
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 |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
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 |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
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 |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
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 |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
MAXILLARY ANTROSTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2959806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
MAXILLARY ANTROSTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2959806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
MAXILLARY & MANDIBULAR VESTIBULOPLASTY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960504
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
MAXILLARY & MANDIBULAR VESTIBULOPLASTY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960504
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
MAXILLA, TUMOR RESECTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960456
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
MAXILLA, TUMOR RESECTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960456
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
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 |
$196.20 |
| Max. Negotiated Rate |
$368.37 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.21
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$368.37
|
| Rate for Payer: Health EOS Commercial |
$356.36
|
| Rate for Payer: HFN Commercial |
$368.37
|
| Rate for Payer: Multiplan Commercial |
$320.32
|
| Rate for Payer: Preferred Network Access Commercial |
$368.37
|
| Rate for Payer: Quartz Beloit One Network |
$196.20
|
| Rate for Payer: Quartz Commercial |
$240.24
|
| Rate for Payer: WEA Trust Commercial |
$220.22
|
| Rate for Payer: WPS Commercial |
$296.57
|
|
|
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 |
$62.09 |
| Max. Negotiated Rate |
$368.37 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.34
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$260.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$200.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$192.19
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$212.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$368.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$356.36
|
| Rate for Payer: HFN Commercial |
$368.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$320.32
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$368.37
|
| Rate for Payer: Quartz Beloit One Network |
$196.20
|
| Rate for Payer: Quartz Commercial |
$260.26
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: United Healthcare PPO |
$300.30
|
| Rate for Payer: WEA Trust Commercial |
$220.22
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$296.57
|
|
|
Mayo, Antibody Stain
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.05 |
| Max. Negotiated Rate |
$377.69 |
| Rate for Payer: Aetna Commercial |
$324.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.36
|
| Rate for Payer: Aetna Managed Medicare |
$101.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$234.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$173.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.27
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$332.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.95
|
| Rate for Payer: Health EOS Commercial |
$321.18
|
| Rate for Payer: HFN Commercial |
$332.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$270.66
|
| Rate for Payer: Multiplan Commercial |
$288.70
|
| Rate for Payer: NAPHCARE Commercial |
$216.53
|
| Rate for Payer: Preferred Network Access Commercial |
$332.01
|
| Rate for Payer: Quartz Beloit One Network |
$176.83
|
| Rate for Payer: Quartz Commercial |
$234.57
|
| Rate for Payer: Quartz Medicare Advantage |
$216.53
|
| Rate for Payer: The Alliance Commercial |
$377.69
|
| Rate for Payer: United Healthcare PPO |
$270.66
|
| Rate for Payer: WEA Trust Commercial |
$198.48
|
| Rate for Payer: WPS Commercial |
$267.29
|
|
|
Mayo, Antibody Stain
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$415.46 |
| Rate for Payer: Aetna Commercial |
$342.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.36
|
| Rate for Payer: Aetna Managed Medicare |
$94.42
|
| Rate for Payer: Anthem Commercial |
$17.79
|
| Rate for Payer: Anthem Medicare Advantage |
$94.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$94.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$94.42
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$342.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$180.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.42
|
| Rate for Payer: Health EOS Commercial |
$328.40
|
| Rate for Payer: HFN Commercial |
$342.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$327.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$94.42
|
| Rate for Payer: Multiplan Commercial |
$288.70
|
| Rate for Payer: NAPHCARE Commercial |
$141.63
|
| Rate for Payer: Preferred Network Access Commercial |
$342.84
|
| Rate for Payer: Quartz Beloit One Network |
$158.79
|
| Rate for Payer: Quartz Commercial |
$205.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.42
|
| Rate for Payer: The Alliance Commercial |
$372.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$94.42
|
| Rate for Payer: WEA Trust Commercial |
$198.48
|
| Rate for Payer: WPS Commercial |
$415.46
|
|
|
Mayo, Antibody Stain
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
CPT 88341
|
| Hospital Charge Code |
4574689
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.83 |
| Max. Negotiated Rate |
$332.01 |
| Rate for Payer: Aetna Commercial |
$324.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$310.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.27
|
| Rate for Payer: Cash Price |
$104.10
|
| Rate for Payer: Cigna Commercial |
$332.01
|
| Rate for Payer: Health EOS Commercial |
$321.18
|
| Rate for Payer: HFN Commercial |
$332.01
|
| Rate for Payer: Multiplan Commercial |
$288.70
|
| Rate for Payer: Preferred Network Access Commercial |
$332.01
|
| Rate for Payer: Quartz Beloit One Network |
$176.83
|
| Rate for Payer: Quartz Commercial |
$216.53
|
| Rate for Payer: WEA Trust Commercial |
$198.48
|
| Rate for Payer: WPS Commercial |
$267.29
|
|
|
Mayo Consult, Outside Slide
|
Professional
|
Both
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.96 |
| Max. Negotiated Rate |
$782.50 |
| Rate for Payer: Aetna Commercial |
$782.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$67.96
|
| Rate for Payer: Anthem Medicare Advantage |
$67.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$67.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$67.96
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$782.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$411.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.96
|
| Rate for Payer: Health EOS Commercial |
$749.55
|
| Rate for Payer: HFN Commercial |
$782.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$347.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$67.96
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$101.95
|
| Rate for Payer: Preferred Network Access Commercial |
$782.50
|
| Rate for Payer: Quartz Beloit One Network |
$362.42
|
| Rate for Payer: Quartz Commercial |
$469.50
|
| Rate for Payer: Quartz Medicare Advantage |
$67.96
|
| Rate for Payer: The Alliance Commercial |
$268.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.96
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$299.04
|
|
|
Mayo Consult, Outside Slide
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$403.60 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$494.21
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
Mayo Consult, Outside Slide
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
4063447
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$39.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.43
|
| Rate for Payer: Anthem Medicare Advantage |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.31
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.31
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.31
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$58.97
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$535.39
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$157.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.31
|
| Rate for Payer: United Healthcare PPO |
$617.76
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: Wellcare Medicare |
$39.31
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
Mayo Consult, w/ History Review
|
Facility
|
IP
|
$792.00
|
|
|
Service Code
|
CPT 88325
|
| Hospital Charge Code |
4574688
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$403.60 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$494.21
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
Mayo Consult, w/ History Review
|
Facility
|
OP
|
$792.00
|
|
|
Service Code
|
CPT 88325
|
| Hospital Charge Code |
4574688
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$179.30 |
| Max. Negotiated Rate |
$757.79 |
| Rate for Payer: Aetna Commercial |
$741.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$708.36
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna Commercial |
$757.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$733.08
|
| Rate for Payer: HFN Commercial |
$757.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$658.94
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$757.79
|
| Rate for Payer: Quartz Beloit One Network |
$403.60
|
| Rate for Payer: Quartz Commercial |
$535.39
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$617.76
|
| Rate for Payer: WEA Trust Commercial |
$453.02
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$610.08
|
|
|
Mayo Consult, w/Slide Prep
|
Facility
|
OP
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.84 |
| Max. Negotiated Rate |
$787.45 |
| Rate for Payer: Aetna Commercial |
$770.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$736.09
|
| Rate for Payer: Aetna Managed Medicare |
$54.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.47
|
| Rate for Payer: Anthem Medicare Advantage |
$54.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$54.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$54.84
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$787.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$54.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$478.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$761.77
|
| Rate for Payer: HFN Commercial |
$787.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$54.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$54.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$54.84
|
| Rate for Payer: Multiplan Commercial |
$684.74
|
| Rate for Payer: NAPHCARE Commercial |
$82.26
|
| Rate for Payer: Preferred Network Access Commercial |
$787.45
|
| Rate for Payer: Quartz Beloit One Network |
$419.40
|
| Rate for Payer: Quartz Commercial |
$556.35
|
| Rate for Payer: Quartz Medicare Advantage |
$54.84
|
| Rate for Payer: The Alliance Commercial |
$219.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.84
|
| Rate for Payer: United Healthcare PPO |
$641.94
|
| Rate for Payer: WEA Trust Commercial |
$470.76
|
| Rate for Payer: Wellcare Medicare |
$54.84
|
| Rate for Payer: WPS Commercial |
$633.96
|
|
|
Mayo Consult, w/Slide Prep
|
Facility
|
IP
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$419.40 |
| Max. Negotiated Rate |
$787.45 |
| Rate for Payer: Aetna Commercial |
$770.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$736.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.64
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$787.45
|
| Rate for Payer: Health EOS Commercial |
$761.77
|
| Rate for Payer: HFN Commercial |
$787.45
|
| Rate for Payer: Multiplan Commercial |
$684.74
|
| Rate for Payer: Preferred Network Access Commercial |
$787.45
|
| Rate for Payer: Quartz Beloit One Network |
$419.40
|
| Rate for Payer: Quartz Commercial |
$513.55
|
| Rate for Payer: WEA Trust Commercial |
$470.76
|
| Rate for Payer: WPS Commercial |
$633.96
|
|
|
Mayo Consult, w/Slide Prep
|
Professional
|
Both
|
$823.00
|
|
|
Service Code
|
CPT 88323
|
| Hospital Charge Code |
4063448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.28 |
| Max. Negotiated Rate |
$813.12 |
| Rate for Payer: Aetna Commercial |
$813.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$736.09
|
| Rate for Payer: Aetna Managed Medicare |
$114.63
|
| Rate for Payer: Anthem Commercial |
$76.28
|
| Rate for Payer: Anthem Medicare Advantage |
$114.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$114.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$114.63
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$813.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$427.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.63
|
| Rate for Payer: Health EOS Commercial |
$778.89
|
| Rate for Payer: HFN Commercial |
$813.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$114.63
|
| Rate for Payer: Multiplan Commercial |
$684.74
|
| Rate for Payer: NAPHCARE Commercial |
$171.94
|
| Rate for Payer: Preferred Network Access Commercial |
$813.12
|
| Rate for Payer: Quartz Beloit One Network |
$376.60
|
| Rate for Payer: Quartz Commercial |
$487.87
|
| Rate for Payer: Quartz Medicare Advantage |
$114.63
|
| Rate for Payer: The Alliance Commercial |
$452.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.63
|
| Rate for Payer: WEA Trust Commercial |
$470.76
|
| Rate for Payer: WPS Commercial |
$504.37
|
|
|
Mayo, Copper Liver Ts
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 82525
|
| Hospital Charge Code |
4860606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
