|
MOUTHPIECE ENDOSCOPIC SNGL USE
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2973196
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
MOUTHPIECE EZ GUARD ADULT 710101
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
2971976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
MOUTHPIECE EZ GUARD ADULT 710101
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
2971976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
MOUTHPIECE EZ PAP #26-23-0747
|
Facility
|
OP
|
$430.00
|
|
| Hospital Charge Code |
2973090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$125.22 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Aetna Managed Medicare |
$125.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$290.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$223.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.26
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.40
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: NAPHCARE Commercial |
$268.32
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$290.68
|
| Rate for Payer: Quartz Medicare Advantage |
$268.32
|
| Rate for Payer: The Alliance Commercial |
$223.60
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
MOUTHPIECE EZ PAP #26-23-0747
|
Facility
|
IP
|
$430.00
|
|
| Hospital Charge Code |
2973090
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$219.13 |
| Max. Negotiated Rate |
$411.42 |
| Rate for Payer: Aetna Commercial |
$402.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$384.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.02
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Cigna Commercial |
$411.42
|
| Rate for Payer: Health EOS Commercial |
$398.01
|
| Rate for Payer: HFN Commercial |
$411.42
|
| Rate for Payer: Multiplan Commercial |
$357.76
|
| Rate for Payer: Preferred Network Access Commercial |
$411.42
|
| Rate for Payer: Quartz Beloit One Network |
$219.13
|
| Rate for Payer: Quartz Commercial |
$268.32
|
| Rate for Payer: WEA Trust Commercial |
$245.96
|
| Rate for Payer: WPS Commercial |
$331.23
|
|
|
MOUTHPIECE IQSPIRO 2-100-1205
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
2974645
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
MOUTHPIECE IQSPIRO 2-100-1205
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
2974645
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$20.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$44.93
|
| Rate for Payer: The Alliance Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
MOUTH PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$41,936.96
|
|
|
Service Code
|
MSDRG 137
|
| Min. Negotiated Rate |
$11,941.99 |
| Max. Negotiated Rate |
$41,936.96 |
| Rate for Payer: Aetna Managed Medicare |
$11,941.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,580.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,972.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,725.63
|
| Rate for Payer: Anthem Medicare Advantage |
$11,941.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,941.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,941.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,941.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,337.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,941.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,515.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,941.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,941.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,941.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,941.99
|
| Rate for Payer: NAPHCARE Commercial |
$17,912.98
|
| Rate for Payer: Quartz Medicare Advantage |
$11,941.99
|
| Rate for Payer: The Alliance Commercial |
$41,936.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,941.99
|
| Rate for Payer: United Healthcare PPO |
$23,756.56
|
| Rate for Payer: Wellcare Medicare |
$11,941.99
|
|
|
MOUTH PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$24,269.44
|
|
|
Service Code
|
MSDRG 138
|
| Min. Negotiated Rate |
$7,293.48 |
| Max. Negotiated Rate |
$24,269.44 |
| Rate for Payer: Aetna Managed Medicare |
$7,293.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,336.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,821.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,080.94
|
| Rate for Payer: Anthem Medicare Advantage |
$7,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,293.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,293.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,631.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,293.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,556.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,293.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,293.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,293.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,293.48
|
| Rate for Payer: NAPHCARE Commercial |
$10,940.22
|
| Rate for Payer: Quartz Medicare Advantage |
$7,293.48
|
| Rate for Payer: The Alliance Commercial |
$24,269.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,293.48
|
| Rate for Payer: United Healthcare PPO |
$13,667.88
|
| Rate for Payer: Wellcare Medicare |
$7,293.48
|
|
|
M-PACI HAND-SCORING STARTER
|
Facility
|
OP
|
$3,795.00
|
|
| Hospital Charge Code |
2973439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,105.10 |
| Max. Negotiated Rate |
$3,631.06 |
| Rate for Payer: Aetna Commercial |
$3,552.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,105.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,565.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,973.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,894.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.80
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,631.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,208.69
|
| Rate for Payer: Health EOS Commercial |
$3,512.65
|
| Rate for Payer: HFN Commercial |
$3,631.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,960.10
|
| Rate for Payer: Multiplan Commercial |
$3,157.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,368.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,933.93
|
| Rate for Payer: Quartz Commercial |
$2,565.42
|
| Rate for Payer: Quartz Medicare Advantage |
$2,368.08
|
| Rate for Payer: The Alliance Commercial |
$1,973.40
|
| Rate for Payer: WEA Trust Commercial |
$2,170.74
|
| Rate for Payer: WPS Commercial |
$2,923.29
|
|
|
M-PACI HAND-SCORING STARTER
|
Facility
|
IP
|
$3,795.00
|
|
| Hospital Charge Code |
2973439
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,933.93 |
| Max. Negotiated Rate |
$3,631.06 |
| Rate for Payer: Aetna Commercial |
$3,552.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,394.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,091.80
|
| Rate for Payer: Cash Price |
$1,138.50
|
| Rate for Payer: Cigna Commercial |
$3,631.06
|
| Rate for Payer: Health EOS Commercial |
$3,512.65
|
| Rate for Payer: HFN Commercial |
$3,631.06
|
| Rate for Payer: Multiplan Commercial |
$3,157.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,631.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,933.93
|
| Rate for Payer: Quartz Commercial |
$2,368.08
|
| Rate for Payer: WEA Trust Commercial |
$2,170.74
|
| Rate for Payer: WPS Commercial |
$2,923.29
|
|
|
MPL Mutation Analysis
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4534672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.34 |
| Max. Negotiated Rate |
$851.55 |
| Rate for Payer: Aetna Commercial |
$833.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.02
|
| Rate for Payer: Aetna Managed Medicare |
$156.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$586.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$259.53
|
| Rate for Payer: Anthem Medicare Advantage |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.34
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$851.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$156.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$517.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$156.34
|
| Rate for Payer: Health EOS Commercial |
$823.78
|
| Rate for Payer: HFN Commercial |
$851.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$581.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$156.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$156.34
|
| Rate for Payer: Multiplan Commercial |
$740.48
|
| Rate for Payer: NAPHCARE Commercial |
$234.51
|
| Rate for Payer: Preferred Network Access Commercial |
$851.55
|
| Rate for Payer: Quartz Beloit One Network |
$453.54
|
| Rate for Payer: Quartz Commercial |
$601.64
|
| Rate for Payer: Quartz Medicare Advantage |
$156.34
|
| Rate for Payer: The Alliance Commercial |
$625.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.34
|
| Rate for Payer: United Healthcare PPO |
$694.20
|
| Rate for Payer: WEA Trust Commercial |
$509.08
|
| Rate for Payer: Wellcare Medicare |
$156.34
|
| Rate for Payer: WPS Commercial |
$685.57
|
|
|
MPL Mutation Analysis
|
Professional
|
Both
|
$890.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4534672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.34 |
| Max. Negotiated Rate |
$879.32 |
| Rate for Payer: Aetna Commercial |
$879.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.02
|
| Rate for Payer: Aetna Managed Medicare |
$156.34
|
| Rate for Payer: Anthem Medicare Advantage |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.34
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$879.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$462.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.34
|
| Rate for Payer: Health EOS Commercial |
$842.30
|
| Rate for Payer: HFN Commercial |
$879.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$551.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$551.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.34
|
| Rate for Payer: Multiplan Commercial |
$740.48
|
| Rate for Payer: NAPHCARE Commercial |
$234.51
|
| Rate for Payer: Preferred Network Access Commercial |
$879.32
|
| Rate for Payer: Quartz Beloit One Network |
$407.26
|
| Rate for Payer: Quartz Commercial |
$527.59
|
| Rate for Payer: Quartz Medicare Advantage |
$156.34
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.34
|
| Rate for Payer: WEA Trust Commercial |
$509.08
|
| Rate for Payer: WPS Commercial |
$687.91
|
|
|
MPL Mutation Analysis
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4534672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$453.54 |
| Max. Negotiated Rate |
$851.55 |
| Rate for Payer: Aetna Commercial |
$833.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.57
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$851.55
|
| Rate for Payer: Health EOS Commercial |
$823.78
|
| Rate for Payer: HFN Commercial |
$851.55
|
| Rate for Payer: Multiplan Commercial |
$740.48
|
| Rate for Payer: Preferred Network Access Commercial |
$851.55
|
| Rate for Payer: Quartz Beloit One Network |
$453.54
|
| Rate for Payer: Quartz Commercial |
$555.36
|
| Rate for Payer: WEA Trust Commercial |
$509.08
|
| Rate for Payer: WPS Commercial |
$685.57
|
|
|
MPL Mutation Analysis to US Labs
|
Professional
|
Both
|
$999.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4938615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.34 |
| Max. Negotiated Rate |
$987.01 |
| Rate for Payer: Aetna Commercial |
$987.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$893.51
|
| Rate for Payer: Aetna Managed Medicare |
$156.34
|
| Rate for Payer: Anthem Medicare Advantage |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.34
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$987.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$519.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.34
|
| Rate for Payer: Health EOS Commercial |
$945.45
|
| Rate for Payer: HFN Commercial |
$987.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$551.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$551.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.34
|
| Rate for Payer: Multiplan Commercial |
$831.17
|
| Rate for Payer: NAPHCARE Commercial |
$234.51
|
| Rate for Payer: Preferred Network Access Commercial |
$987.01
|
| Rate for Payer: Quartz Beloit One Network |
$457.14
|
| Rate for Payer: Quartz Commercial |
$592.21
|
| Rate for Payer: Quartz Medicare Advantage |
$156.34
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.34
|
| Rate for Payer: WEA Trust Commercial |
$571.43
|
| Rate for Payer: WPS Commercial |
$687.91
|
|
|
MPL Mutation Analysis to US Labs
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4938615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$509.09 |
| Max. Negotiated Rate |
$955.84 |
| Rate for Payer: Aetna Commercial |
$935.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$893.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$550.65
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$955.84
|
| Rate for Payer: Health EOS Commercial |
$924.67
|
| Rate for Payer: HFN Commercial |
$955.84
|
| Rate for Payer: Multiplan Commercial |
$831.17
|
| Rate for Payer: Preferred Network Access Commercial |
$955.84
|
| Rate for Payer: Quartz Beloit One Network |
$509.09
|
| Rate for Payer: Quartz Commercial |
$623.38
|
| Rate for Payer: WEA Trust Commercial |
$571.43
|
| Rate for Payer: WPS Commercial |
$769.53
|
|
|
MPL Mutation Analysis to US Labs
|
Facility
|
OP
|
$999.00
|
|
|
Service Code
|
CPT 81402
|
| Hospital Charge Code |
4938615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.34 |
| Max. Negotiated Rate |
$955.84 |
| Rate for Payer: Aetna Commercial |
$935.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$893.51
|
| Rate for Payer: Aetna Managed Medicare |
$156.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$586.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$259.53
|
| Rate for Payer: Anthem Medicare Advantage |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$550.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.34
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cash Price |
$299.70
|
| Rate for Payer: Cigna Commercial |
$955.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$156.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$581.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$156.34
|
| Rate for Payer: Health EOS Commercial |
$924.67
|
| Rate for Payer: HFN Commercial |
$955.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$581.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$156.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$156.34
|
| Rate for Payer: Multiplan Commercial |
$831.17
|
| Rate for Payer: NAPHCARE Commercial |
$234.51
|
| Rate for Payer: Preferred Network Access Commercial |
$955.84
|
| Rate for Payer: Quartz Beloit One Network |
$509.09
|
| Rate for Payer: Quartz Commercial |
$675.32
|
| Rate for Payer: Quartz Medicare Advantage |
$156.34
|
| Rate for Payer: The Alliance Commercial |
$625.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.34
|
| Rate for Payer: United Healthcare PPO |
$779.22
|
| Rate for Payer: WEA Trust Commercial |
$571.43
|
| Rate for Payer: Wellcare Medicare |
$156.34
|
| Rate for Payer: WPS Commercial |
$769.53
|
|
|
MPL S505 Mutation
|
Facility
|
OP
|
$300.00
|
|
| Hospital Charge Code |
2942932
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.36 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Aetna Managed Medicare |
$87.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$202.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$149.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$174.60
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.00
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: NAPHCARE Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$202.80
|
| Rate for Payer: Quartz Medicare Advantage |
$187.20
|
| Rate for Payer: The Alliance Commercial |
$156.00
|
| Rate for Payer: United Healthcare PPO |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
MPL S505 Mutation
|
Facility
|
IP
|
$300.00
|
|
| Hospital Charge Code |
2942932
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$152.88 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$280.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.36
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$287.04
|
| Rate for Payer: Health EOS Commercial |
$277.68
|
| Rate for Payer: HFN Commercial |
$287.04
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$287.04
|
| Rate for Payer: Quartz Beloit One Network |
$152.88
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
MPL S505 Mutation
|
Professional
|
Both
|
$300.00
|
|
| Hospital Charge Code |
2942932
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.28 |
| Max. Negotiated Rate |
$296.40 |
| Rate for Payer: Aetna Commercial |
$296.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$268.32
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$296.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.20
|
| Rate for Payer: Health EOS Commercial |
$283.92
|
| Rate for Payer: HFN Commercial |
$296.40
|
| Rate for Payer: Multiplan Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$296.40
|
| Rate for Payer: Quartz Beloit One Network |
$137.28
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$171.60
|
| Rate for Payer: WPS Commercial |
$231.09
|
|
|
MPL W515 Mutation
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2942931
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
MPL W515 Mutation
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2942931
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
MPL W515 Mutation
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2942931
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
MRA Abdomen w Contrast
|
Facility
|
OP
|
$6,080.00
|
|
| Hospital Charge Code |
675635
|
| Min. Negotiated Rate |
$1,770.50 |
| Max. Negotiated Rate |
$5,817.34 |
| Rate for Payer: Aetna Commercial |
$5,690.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Aetna Managed Medicare |
$1,770.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,110.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,161.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,035.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,351.30
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,817.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,538.56
|
| Rate for Payer: Health EOS Commercial |
$5,627.65
|
| Rate for Payer: HFN Commercial |
$5,817.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,742.40
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: NAPHCARE Commercial |
$3,793.92
|
| Rate for Payer: Preferred Network Access Commercial |
$5,817.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,098.37
|
| Rate for Payer: Quartz Commercial |
$4,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,793.92
|
| Rate for Payer: The Alliance Commercial |
$3,161.60
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
|
MRA Abdomen w Contrast
|
Professional
|
Both
|
$6,080.00
|
|
| Hospital Charge Code |
675635
|
| Min. Negotiated Rate |
$2,782.21 |
| Max. Negotiated Rate |
$6,007.04 |
| Rate for Payer: Aetna Commercial |
$6,007.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$6,007.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,161.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,793.92
|
| Rate for Payer: Health EOS Commercial |
$5,754.11
|
| Rate for Payer: HFN Commercial |
$6,007.04
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: Preferred Network Access Commercial |
$6,007.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,782.21
|
| Rate for Payer: Quartz Commercial |
$3,604.22
|
| Rate for Payer: The Alliance Commercial |
$3,161.60
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
