|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 12MM 42-5224-004-12
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 13MM 42-5224-004-13
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 13MM 42-5224-004-13
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
IP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,453.61 |
| Max. Negotiated Rate |
$8,361.88 |
| Rate for Payer: Aetna Commercial |
$8,180.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,817.17
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,361.88
|
| Rate for Payer: Health EOS Commercial |
$8,089.21
|
| Rate for Payer: HFN Commercial |
$8,361.88
|
| Rate for Payer: Multiplan Commercial |
$7,271.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.61
|
| Rate for Payer: Quartz Commercial |
$5,453.40
|
| Rate for Payer: WEA Trust Commercial |
$4,998.95
|
| Rate for Payer: WPS Commercial |
$6,732.22
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 14MM RT 42-5224-004-14
|
Facility
|
OP
|
$9,089.00
|
|
| Hospital Charge Code |
5286608
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,544.92 |
| Max. Negotiated Rate |
$36,356.00 |
| Rate for Payer: Aetna Commercial |
$8,180.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,816.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,544.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,907.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,544.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,362.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,817.17
|
| Rate for Payer: Cash Price |
$2,726.70
|
| Rate for Payer: Cigna Commercial |
$8,361.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,086.20
|
| Rate for Payer: Health EOS Commercial |
$8,089.21
|
| Rate for Payer: HFN Commercial |
$8,361.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,816.75
|
| Rate for Payer: Multiplan Commercial |
$7,271.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,453.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,361.88
|
| Rate for Payer: Quartz Beloit One Network |
$4,453.61
|
| Rate for Payer: Quartz Commercial |
$5,907.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5,453.40
|
| Rate for Payer: The Alliance Commercial |
$36,356.00
|
| Rate for Payer: WEA Trust Commercial |
$4,998.95
|
| Rate for Payer: WPS Commercial |
$6,732.22
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 16MM 42-5224-004-16
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962675
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 18MM 42-5224-004-18
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962677
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
OP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,364.88 |
| Max. Negotiated Rate |
$33,784.00 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,364.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,489.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,223.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,054.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,726.38
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,334.50
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,489.90
|
| Rate for Payer: Quartz Medicare Advantage |
$5,067.60
|
| Rate for Payer: The Alliance Commercial |
$33,784.00
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
PERSONA ARTICULAR SURFACE PS VE 3-5 CD 20MM 42-5224-004-20
|
Facility
|
IP
|
$8,446.00
|
|
| Hospital Charge Code |
3962678
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,138.54 |
| Max. Negotiated Rate |
$7,770.32 |
| Rate for Payer: Aetna Commercial |
$7,601.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,263.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,476.38
|
| Rate for Payer: Cash Price |
$2,533.80
|
| Rate for Payer: Cigna Commercial |
$7,770.32
|
| Rate for Payer: Health EOS Commercial |
$7,516.94
|
| Rate for Payer: HFN Commercial |
$7,770.32
|
| Rate for Payer: Multiplan Commercial |
$6,756.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,067.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,770.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,138.54
|
| Rate for Payer: Quartz Commercial |
$5,067.60
|
| Rate for Payer: WEA Trust Commercial |
$4,645.30
|
| Rate for Payer: WPS Commercial |
$6,255.95
|
|
|
Pertussis toxin IgA
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.56
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgA
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgA
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.90
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.19
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.19
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.19
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.19
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$19.78
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13.19
|
| Rate for Payer: The Alliance Commercial |
$52.76
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$13.19
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.56
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.90
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.19
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.19
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.19
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.19
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$19.78
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$13.19
|
| Rate for Payer: The Alliance Commercial |
$52.76
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.19
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$13.19
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pertussis toxin IgG
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86615
|
| Hospital Charge Code |
3794218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Pessary, non rubber, any type A4562
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$29.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$63.00
|
| Rate for Payer: The Alliance Commercial |
$420.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
Pessary, non rubber, any type A4562
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$209.26 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$209.26
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
Pessary, non rubber, any type A4562
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
3142835
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
IP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$485.59 |
| Max. Negotiated Rate |
$911.72 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$594.60
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
PESSARY SHAATZ/FOLD PESSARY 3-1/4 MXKPSH3-1/4
|
Facility
|
OP
|
$991.00
|
|
| Hospital Charge Code |
3072500
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.48 |
| Max. Negotiated Rate |
$3,964.00 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Aetna Managed Medicare |
$277.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$644.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.56
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.25
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$644.15
|
| Rate for Payer: Quartz Medicare Advantage |
$594.60
|
| Rate for Payer: The Alliance Commercial |
$3,964.00
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Professional
|
Both
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,407.56 |
| Max. Negotiated Rate |
$8,231.85 |
| Rate for Payer: Aetna Commercial |
$3,039.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$3,039.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,599.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,919.40
|
| Rate for Payer: Health EOS Commercial |
$2,911.09
|
| Rate for Payer: HFN Commercial |
$3,039.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,231.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,231.85
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,039.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,407.56
|
| Rate for Payer: Quartz Commercial |
$1,823.43
|
| Rate for Payer: The Alliance Commercial |
$1,599.50
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
OP
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,546.32 |
| Max. Negotiated Rate |
$6,185.28 |
| Rate for Payer: Aetna Commercial |
$2,879.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,546.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,079.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,273.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,695.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,546.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,546.32
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$2,943.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,546.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,790.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,546.32
|
| Rate for Payer: Health EOS Commercial |
$2,847.11
|
| Rate for Payer: HFN Commercial |
$2,943.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,752.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,546.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,546.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,546.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,546.32
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,319.48
|
| Rate for Payer: Preferred Network Access Commercial |
$2,943.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.51
|
| Rate for Payer: Quartz Commercial |
$2,079.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,546.32
|
| Rate for Payer: The Alliance Commercial |
$6,185.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,546.32
|
| Rate for Payer: United Healthcare PPO |
$2,399.25
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: Wellcare Medicare |
$1,546.32
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
|
PET Brain Imaging Metabolic Evaluation
|
Facility
|
IP
|
$3,199.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
2587013
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,567.51 |
| Max. Negotiated Rate |
$2,943.08 |
| Rate for Payer: Aetna Commercial |
$2,879.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,751.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,695.47
|
| Rate for Payer: Cash Price |
$959.70
|
| Rate for Payer: Cigna Commercial |
$2,943.08
|
| Rate for Payer: Health EOS Commercial |
$2,847.11
|
| Rate for Payer: HFN Commercial |
$2,943.08
|
| Rate for Payer: Multiplan Commercial |
$2,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,919.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,943.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,567.51
|
| Rate for Payer: Quartz Commercial |
$1,919.40
|
| Rate for Payer: WEA Trust Commercial |
$1,759.45
|
| Rate for Payer: WPS Commercial |
$2,369.50
|
|
