|
OT Therapeutic Exercise Charges
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
750901
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
OT Therapeutic Exercise Charges
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
750901
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: United Healthcare PPO |
$145.50
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
OT Therapeutic Exercise Charges
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
750901
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Aetna Commercial |
$184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$184.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$97.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$176.54
|
| Rate for Payer: HFN Commercial |
$184.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.58
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: Preferred Network Access Commercial |
$184.30
|
| Rate for Payer: Quartz Beloit One Network |
$85.36
|
| Rate for Payer: Quartz Commercial |
$110.58
|
| Rate for Payer: The Alliance Commercial |
$97.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
OT TH Therapeutic Exercise Chg
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97110 GO,95
|
| Hospital Charge Code |
5583096
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT TH Therapeutic Exercise Chg
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
CPT 97110 GO,95
|
| Hospital Charge Code |
5583096
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$98.12 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.80
|
| Rate for Payer: Health EOS Commercial |
$202.93
|
| Rate for Payer: HFN Commercial |
$211.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$102.58
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: Preferred Network Access Commercial |
$211.85
|
| Rate for Payer: Quartz Beloit One Network |
$98.12
|
| Rate for Payer: Quartz Commercial |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$111.50
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT TH Therapeutic Exercise Chg
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97110 GO,95
|
| Hospital Charge Code |
5583096
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Ultrasound Charges
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
CPT 97035 GO
|
| Hospital Charge Code |
2468809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
OT Ultrasound Charges
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
CPT 97035 GO
|
| Hospital Charge Code |
2468809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: United Healthcare PPO |
$119.25
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
OT Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 97014
|
| Hospital Charge Code |
5254608
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$44.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.80
|
| Rate for Payer: The Alliance Commercial |
$632.00
|
| Rate for Payer: United Healthcare PPO |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
OT Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 97014
|
| Hospital Charge Code |
5254608
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
OT Wheelchair Management Charges
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97542 GO
|
| Hospital Charge Code |
750928
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Wheelchair Management Charges
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97542 GO
|
| Hospital Charge Code |
750928
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Outback Re-Entry Catheter
|
Facility
|
OP
|
$13,475.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
4534609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,773.00 |
| Max. Negotiated Rate |
$53,900.00 |
| Rate for Payer: Aetna Commercial |
$12,127.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,588.50
|
| Rate for Payer: Aetna Managed Medicare |
$3,773.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,758.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,737.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,468.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,141.75
|
| Rate for Payer: Cash Price |
$4,042.50
|
| Rate for Payer: Cigna Commercial |
$12,397.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,540.61
|
| Rate for Payer: Health EOS Commercial |
$11,992.75
|
| Rate for Payer: HFN Commercial |
$12,397.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,106.25
|
| Rate for Payer: Multiplan Commercial |
$10,780.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,085.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,397.00
|
| Rate for Payer: Quartz Beloit One Network |
$6,602.75
|
| Rate for Payer: Quartz Commercial |
$8,758.75
|
| Rate for Payer: Quartz Medicare Advantage |
$8,085.00
|
| Rate for Payer: The Alliance Commercial |
$53,900.00
|
| Rate for Payer: WEA Trust Commercial |
$7,411.25
|
| Rate for Payer: WPS Commercial |
$9,980.93
|
|
|
Outback Re-Entry Catheter
|
Facility
|
IP
|
$13,475.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
4534609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,602.75 |
| Max. Negotiated Rate |
$12,397.00 |
| Rate for Payer: Aetna Commercial |
$12,127.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,588.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,141.75
|
| Rate for Payer: Cash Price |
$4,042.50
|
| Rate for Payer: Cigna Commercial |
$12,397.00
|
| Rate for Payer: Health EOS Commercial |
$11,992.75
|
| Rate for Payer: HFN Commercial |
$12,397.00
|
| Rate for Payer: Multiplan Commercial |
$10,780.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,085.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,397.00
|
| Rate for Payer: Quartz Beloit One Network |
$6,602.75
|
| Rate for Payer: Quartz Commercial |
$8,085.00
|
| Rate for Payer: WEA Trust Commercial |
$7,411.25
|
| Rate for Payer: WPS Commercial |
$9,980.93
|
|
|
OUTFLOW TUBE SET HYSTEROSCIOPIC TRUCLEAR LEGACY FLUID MANAGEMENT 7209823
|
Facility
|
IP
|
$500.00
|
|
| Hospital Charge Code |
5797666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$450.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$460.00
|
| Rate for Payer: Health EOS Commercial |
$445.00
|
| Rate for Payer: HFN Commercial |
$460.00
|
| Rate for Payer: Multiplan Commercial |
$400.00
|
| Rate for Payer: NAPHCARE Commercial |
$300.00
|
| Rate for Payer: Preferred Network Access Commercial |
$460.00
|
| Rate for Payer: Quartz Beloit One Network |
$245.00
|
| Rate for Payer: Quartz Commercial |
$300.00
|
| Rate for Payer: WEA Trust Commercial |
$275.00
|
| Rate for Payer: WPS Commercial |
$370.35
|
|
|
OUTFLOW TUBE SET HYSTEROSCIOPIC TRUCLEAR LEGACY FLUID MANAGEMENT 7209823
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
5797666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$450.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.00
|
| Rate for Payer: Aetna Managed Medicare |
$140.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$325.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$250.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$460.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.80
|
| Rate for Payer: Health EOS Commercial |
$445.00
|
| Rate for Payer: HFN Commercial |
$460.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$375.00
|
| Rate for Payer: Multiplan Commercial |
$400.00
|
| Rate for Payer: NAPHCARE Commercial |
$300.00
|
| Rate for Payer: Preferred Network Access Commercial |
$460.00
|
| Rate for Payer: Quartz Beloit One Network |
$245.00
|
| Rate for Payer: Quartz Commercial |
$325.00
|
| Rate for Payer: Quartz Medicare Advantage |
$300.00
|
| Rate for Payer: The Alliance Commercial |
$2,000.00
|
| Rate for Payer: WEA Trust Commercial |
$275.00
|
| Rate for Payer: WPS Commercial |
$370.35
|
|
|
Outpatient IM/SQ Injections
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4602731
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Outpatient IM/SQ Injections
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4602731
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$69.63 |
| Max. Negotiated Rate |
$278.52 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.04
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: The Alliance Commercial |
$278.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Ova and Parasites
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$201.48 |
| Rate for Payer: Aetna Commercial |
$197.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$188.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.07
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$201.48
|
| Rate for Payer: Health EOS Commercial |
$194.91
|
| Rate for Payer: HFN Commercial |
$201.48
|
| Rate for Payer: Multiplan Commercial |
$175.20
|
| Rate for Payer: NAPHCARE Commercial |
$131.40
|
| Rate for Payer: Preferred Network Access Commercial |
$201.48
|
| Rate for Payer: Quartz Beloit One Network |
$107.31
|
| Rate for Payer: Quartz Commercial |
$131.40
|
| Rate for Payer: WEA Trust Commercial |
$120.45
|
| Rate for Payer: WPS Commercial |
$162.21
|
|
|
Ova and Parasites
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.42 |
| Max. Negotiated Rate |
$208.05 |
| Rate for Payer: Aetna Commercial |
$208.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$188.34
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$208.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.40
|
| Rate for Payer: Health EOS Commercial |
$199.29
|
| Rate for Payer: HFN Commercial |
$208.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.42
|
| Rate for Payer: Multiplan Commercial |
$175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$208.05
|
| Rate for Payer: Quartz Beloit One Network |
$96.36
|
| Rate for Payer: Quartz Commercial |
$124.83
|
| Rate for Payer: The Alliance Commercial |
$109.50
|
| Rate for Payer: WEA Trust Commercial |
$120.45
|
| Rate for Payer: WPS Commercial |
$162.21
|
|
|
Ova and Parasites
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$201.48 |
| Rate for Payer: Aetna Commercial |
$197.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$188.34
|
| Rate for Payer: Aetna Managed Medicare |
$8.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.77
|
| Rate for Payer: Anthem Medicaid |
$9.20
|
| Rate for Payer: Anthem Medicare Advantage |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.90
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$201.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.55
|
| Rate for Payer: Dean Health Medicaid |
$9.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.90
|
| Rate for Payer: Health EOS Commercial |
$194.91
|
| Rate for Payer: HFN Commercial |
$201.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.90
|
| Rate for Payer: Managed Health Services Medicaid |
$9.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.90
|
| Rate for Payer: Multiplan Commercial |
$175.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.35
|
| Rate for Payer: Preferred Network Access Commercial |
$201.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$107.31
|
| Rate for Payer: Quartz Commercial |
$142.35
|
| Rate for Payer: Quartz Medicare Advantage |
$8.90
|
| Rate for Payer: The Alliance Commercial |
$35.60
|
| Rate for Payer: United Healthcare Medicaid |
$9.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.90
|
| Rate for Payer: United Healthcare PPO |
$164.25
|
| Rate for Payer: WEA Trust Commercial |
$120.45
|
| Rate for Payer: Wellcare Medicare |
$8.90
|
| Rate for Payer: WMAP Medicaid |
$9.20
|
| Rate for Payer: WPS Commercial |
$162.21
|
|
|
Ova and Parasites Smears 87177PP
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
3190193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$8.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.77
|
| Rate for Payer: Anthem Medicaid |
$9.20
|
| Rate for Payer: Anthem Medicare Advantage |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.90
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.32
|
| Rate for Payer: Dean Health Medicaid |
$9.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.90
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.90
|
| Rate for Payer: Managed Health Services Medicaid |
$9.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.90
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$13.35
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$8.90
|
| Rate for Payer: The Alliance Commercial |
$35.60
|
| Rate for Payer: United Healthcare Medicaid |
$9.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.90
|
| Rate for Payer: United Healthcare PPO |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: Wellcare Medicare |
$8.90
|
| Rate for Payer: WMAP Medicaid |
$9.20
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
Ova and Parasites Smears 87177PP
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
3190193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
Ova & Parasite, Quest Confirmation
|
Facility
|
IP
|
$13.30
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
983349
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: WEA Trust Commercial |
$7.32
|
| Rate for Payer: WPS Commercial |
$9.85
|
| Rate for Payer: Aetna Commercial |
$11.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.05
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$12.24
|
| Rate for Payer: Health EOS Commercial |
$11.84
|
| Rate for Payer: HFN Commercial |
$12.24
|
| Rate for Payer: Multiplan Commercial |
$10.64
|
| Rate for Payer: NAPHCARE Commercial |
$7.98
|
| Rate for Payer: Preferred Network Access Commercial |
$12.24
|
| Rate for Payer: Quartz Beloit One Network |
$6.52
|
| Rate for Payer: Quartz Commercial |
$7.98
|
|
|
Ova & Parasite, Quest Confirmation
|
Facility
|
OP
|
$13.30
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
983349
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$11.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11.44
|
| Rate for Payer: Aetna Managed Medicare |
$8.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.77
|
| Rate for Payer: Anthem Medicaid |
$9.20
|
| Rate for Payer: Anthem Medicare Advantage |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.90
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$12.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.44
|
| Rate for Payer: Dean Health Medicaid |
$9.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.90
|
| Rate for Payer: Health EOS Commercial |
$11.84
|
| Rate for Payer: HFN Commercial |
$12.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.90
|
| Rate for Payer: Managed Health Services Medicaid |
$9.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.90
|
| Rate for Payer: Multiplan Commercial |
$10.64
|
| Rate for Payer: NAPHCARE Commercial |
$13.35
|
| Rate for Payer: Preferred Network Access Commercial |
$12.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$6.52
|
| Rate for Payer: Quartz Commercial |
$8.64
|
| Rate for Payer: Quartz Medicare Advantage |
$8.90
|
| Rate for Payer: The Alliance Commercial |
$35.60
|
| Rate for Payer: United Healthcare Medicaid |
$9.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.90
|
| Rate for Payer: United Healthcare PPO |
$9.98
|
| Rate for Payer: WEA Trust Commercial |
$7.32
|
| Rate for Payer: Wellcare Medicare |
$8.90
|
| Rate for Payer: WMAP Medicaid |
$9.20
|
| Rate for Payer: WPS Commercial |
$9.85
|
|
