|
Opiates Meconium
|
Professional
|
Both
|
$38.00
|
|
| Hospital Charge Code |
2942889
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.72 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.80
|
| Rate for Payer: Health EOS Commercial |
$34.58
|
| Rate for Payer: HFN Commercial |
$36.10
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: Preferred Network Access Commercial |
$36.10
|
| Rate for Payer: Quartz Beloit One Network |
$16.72
|
| Rate for Payer: Quartz Commercial |
$21.66
|
| Rate for Payer: The Alliance Commercial |
$19.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Opiates Meconium
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2942889
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Opiates serum
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
5144621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Opiates serum
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
5144621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.25
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$35.40
|
| Rate for Payer: The Alliance Commercial |
$236.00
|
| Rate for Payer: United Healthcare PPO |
$44.25
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Opiates serum
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
5144621
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$80.06 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
OPTION ELITE IVC FILTER
|
Facility
|
OP
|
$7,260.00
|
|
| Hospital Charge Code |
6175145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,032.80 |
| Max. Negotiated Rate |
$29,040.00 |
| Rate for Payer: Aetna Commercial |
$6,534.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,243.60
|
| Rate for Payer: Aetna Managed Medicare |
$2,032.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,719.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,630.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,484.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,847.80
|
| Rate for Payer: Cash Price |
$2,178.00
|
| Rate for Payer: Cigna Commercial |
$6,679.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,062.70
|
| Rate for Payer: Health EOS Commercial |
$6,461.40
|
| Rate for Payer: HFN Commercial |
$6,679.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,445.00
|
| Rate for Payer: Multiplan Commercial |
$5,808.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,679.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,557.40
|
| Rate for Payer: Quartz Commercial |
$4,719.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,356.00
|
| Rate for Payer: The Alliance Commercial |
$29,040.00
|
| Rate for Payer: WEA Trust Commercial |
$3,993.00
|
| Rate for Payer: WPS Commercial |
$5,377.48
|
|
|
OPTION ELITE IVC FILTER
|
Facility
|
IP
|
$7,260.00
|
|
| Hospital Charge Code |
6175145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,557.40 |
| Max. Negotiated Rate |
$6,679.20 |
| Rate for Payer: Aetna Commercial |
$6,534.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,243.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,847.80
|
| Rate for Payer: Cash Price |
$2,178.00
|
| Rate for Payer: Cigna Commercial |
$6,679.20
|
| Rate for Payer: Health EOS Commercial |
$6,461.40
|
| Rate for Payer: HFN Commercial |
$6,679.20
|
| Rate for Payer: Multiplan Commercial |
$5,808.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,679.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,557.40
|
| Rate for Payer: Quartz Commercial |
$4,356.00
|
| Rate for Payer: WEA Trust Commercial |
$3,993.00
|
| Rate for Payer: WPS Commercial |
$5,377.48
|
|
|
OPTOKINETIC NYSTAGMUS TEST 92544
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
CPT 92544
|
| Hospital Charge Code |
3015334
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$61.85 |
| Rate for Payer: Aetna Commercial |
$49.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$44.72
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cigna Commercial |
$49.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.20
|
| Rate for Payer: Health EOS Commercial |
$47.32
|
| Rate for Payer: HFN Commercial |
$49.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.85
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: Preferred Network Access Commercial |
$49.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.88
|
| Rate for Payer: Quartz Commercial |
$29.64
|
| Rate for Payer: The Alliance Commercial |
$26.00
|
| Rate for Payer: United Healthcare Medicaid |
$24.16
|
| Rate for Payer: WEA Trust Commercial |
$28.60
|
| Rate for Payer: WPS Commercial |
$38.52
|
|
|
Orange (prong O.D.: 4.0mm) - RAM Cannula
|
Facility
|
OP
|
$223.00
|
|
| Hospital Charge Code |
5983678
|
|
Hospital Revenue Code
|
271
|
| 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 |
$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: 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: 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 |
$167.25
|
| 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: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Orange (prong O.D.: 4.0mm) - RAM Cannula
|
Facility
|
IP
|
$223.00
|
|
| Hospital Charge Code |
5983678
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
OraRisk HPV
|
Facility
|
IP
|
$298.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
3710842
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.02 |
| Max. Negotiated Rate |
$274.16 |
| Rate for Payer: Aetna Commercial |
$268.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.94
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$274.16
|
| Rate for Payer: Health EOS Commercial |
$265.22
|
| Rate for Payer: HFN Commercial |
$274.16
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: NAPHCARE Commercial |
$178.80
|
| Rate for Payer: Preferred Network Access Commercial |
$274.16
|
| Rate for Payer: Quartz Beloit One Network |
$146.02
|
| Rate for Payer: Quartz Commercial |
$178.80
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
OraRisk HPV
|
Facility
|
OP
|
$298.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
3710842
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$274.16 |
| Rate for Payer: Aetna Commercial |
$268.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.28
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$274.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.76
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$265.22
|
| Rate for Payer: HFN Commercial |
$274.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$274.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$146.02
|
| Rate for Payer: Quartz Commercial |
$193.70
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$223.50
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
OraRisk HPV
|
Professional
|
Both
|
$298.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
3710842
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.87 |
| Max. Negotiated Rate |
$283.10 |
| Rate for Payer: Aetna Commercial |
$283.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.28
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$283.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$149.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.80
|
| Rate for Payer: Health EOS Commercial |
$271.18
|
| Rate for Payer: HFN Commercial |
$283.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: Preferred Network Access Commercial |
$283.10
|
| Rate for Payer: Quartz Beloit One Network |
$131.12
|
| Rate for Payer: Quartz Commercial |
$169.86
|
| Rate for Payer: The Alliance Commercial |
$149.00
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
ORBITAL BLOWOUT FRACTURE
|
Facility
|
OP
|
$4,324.00
|
|
| Hospital Charge Code |
2959853
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,210.72 |
| Max. Negotiated Rate |
$17,296.00 |
| Rate for Payer: Aetna Commercial |
$3,891.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,210.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,810.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,162.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,075.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$3,978.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,419.71
|
| Rate for Payer: Health EOS Commercial |
$3,848.36
|
| Rate for Payer: HFN Commercial |
$3,978.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,243.00
|
| Rate for Payer: Multiplan Commercial |
$3,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
| Rate for Payer: Quartz Commercial |
$2,810.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,594.40
|
| Rate for Payer: The Alliance Commercial |
$17,296.00
|
| Rate for Payer: WEA Trust Commercial |
$2,378.20
|
| Rate for Payer: WPS Commercial |
$3,202.79
|
|
|
ORBITAL BLOWOUT FRACTURE
|
Facility
|
IP
|
$4,324.00
|
|
| Hospital Charge Code |
2959853
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,118.76 |
| Max. Negotiated Rate |
$3,978.08 |
| Rate for Payer: Aetna Commercial |
$3,891.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,718.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,291.72
|
| Rate for Payer: Cash Price |
$1,297.20
|
| Rate for Payer: Cigna Commercial |
$3,978.08
|
| Rate for Payer: Health EOS Commercial |
$3,848.36
|
| Rate for Payer: HFN Commercial |
$3,978.08
|
| Rate for Payer: Multiplan Commercial |
$3,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,594.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,978.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,118.76
|
| Rate for Payer: Quartz Commercial |
$2,594.40
|
| Rate for Payer: WEA Trust Commercial |
$2,378.20
|
| Rate for Payer: WPS Commercial |
$3,202.79
|
|
|
ORBITAL PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$66,979.00
|
|
|
Service Code
|
MSDRG 113
|
| Min. Negotiated Rate |
$24,093.32 |
| Max. Negotiated Rate |
$66,979.00 |
| Rate for Payer: Aetna Managed Medicare |
$24,093.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52,659.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40,363.31
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38,347.78
|
| Rate for Payer: Anthem Medicare Advantage |
$24,093.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24,093.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24,093.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24,093.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42,569.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24,093.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48,892.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24,093.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24,093.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24,093.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24,093.32
|
| Rate for Payer: NAPHCARE Commercial |
$36,139.98
|
| Rate for Payer: Quartz Medicare Advantage |
$24,093.32
|
| Rate for Payer: The Alliance Commercial |
$66,979.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24,093.32
|
| Rate for Payer: United Healthcare PPO |
$38,063.32
|
| Rate for Payer: Wellcare Medicare |
$24,093.32
|
|
|
ORBITAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$33,069.00
|
|
|
Service Code
|
MSDRG 114
|
| Min. Negotiated Rate |
$11,895.34 |
| Max. Negotiated Rate |
$33,069.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,895.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,805.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,779.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,791.94
|
| Rate for Payer: Anthem Medicare Advantage |
$11,895.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,895.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,895.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,895.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,860.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,895.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,020.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,895.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,895.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,895.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,895.34
|
| Rate for Payer: NAPHCARE Commercial |
$17,843.01
|
| Rate for Payer: Quartz Medicare Advantage |
$11,895.34
|
| Rate for Payer: The Alliance Commercial |
$33,069.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,895.34
|
| Rate for Payer: United Healthcare PPO |
$18,699.96
|
| Rate for Payer: Wellcare Medicare |
$11,895.34
|
|
|
ORCHIECTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960259
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
ORCHIECTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960259
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH
|
Facility
|
OP
|
$13,678.24
|
|
|
Service Code
|
CPT 54530
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,419.56 |
| Max. Negotiated Rate |
$13,678.24 |
| Rate for Payer: Aetna Managed Medicare |
$3,419.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,419.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,419.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,419.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,419.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,419.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,720.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,419.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,419.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,419.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,419.56
|
| Rate for Payer: NAPHCARE Commercial |
$5,129.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.56
|
| Rate for Payer: The Alliance Commercial |
$13,678.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,419.56
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,419.56
|
|
|
ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH
|
Facility
|
OP
|
$13,782.96
|
|
|
Service Code
|
CPT 54520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$13,782.96 |
| Rate for Payer: Aetna Managed Medicare |
$3,445.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,445.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,445.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,445.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,818.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,445.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,445.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,445.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,445.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,168.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,445.74
|
| Rate for Payer: The Alliance Commercial |
$13,782.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,445.74
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,445.74
|
|
|
ORCHIOPEXY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
ORCHIOPEXY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
Organic Acids, Full Panel, Urine
|
Professional
|
Both
|
$969.00
|
|
|
Service Code
|
CPT 83918
|
| Hospital Charge Code |
978030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$920.55 |
| Rate for Payer: Aetna Commercial |
$920.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.34
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$920.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$484.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$581.40
|
| Rate for Payer: Health EOS Commercial |
$881.79
|
| Rate for Payer: HFN Commercial |
$920.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.31
|
| Rate for Payer: Multiplan Commercial |
$775.20
|
| Rate for Payer: Preferred Network Access Commercial |
$920.55
|
| Rate for Payer: Quartz Beloit One Network |
$426.36
|
| Rate for Payer: Quartz Commercial |
$552.33
|
| Rate for Payer: The Alliance Commercial |
$484.50
|
| Rate for Payer: WEA Trust Commercial |
$532.95
|
| Rate for Payer: WPS Commercial |
$717.74
|
|
|
Organic Acids, Full Panel, Urine
|
Facility
|
OP
|
$969.00
|
|
|
Service Code
|
CPT 83918
|
| Hospital Charge Code |
978030
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.14 |
| Max. Negotiated Rate |
$891.48 |
| Rate for Payer: Aetna Commercial |
$872.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.18
|
| Rate for Payer: Anthem Medicaid |
$23.14
|
| Rate for Payer: Anthem Medicare Advantage |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.60
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cash Price |
$290.70
|
| Rate for Payer: Cigna Commercial |
$891.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$542.25
|
| Rate for Payer: Dean Health Medicaid |
$23.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23.60
|
| Rate for Payer: Health EOS Commercial |
$862.41
|
| Rate for Payer: HFN Commercial |
$891.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$23.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.60
|
| Rate for Payer: Managed Health Services Medicaid |
$24.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23.60
|
| Rate for Payer: Multiplan Commercial |
$775.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$891.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23.14
|
| Rate for Payer: Quartz Beloit One Network |
$474.81
|
| Rate for Payer: Quartz Commercial |
$629.85
|
| Rate for Payer: Quartz Medicare Advantage |
$23.60
|
| Rate for Payer: The Alliance Commercial |
$94.40
|
| Rate for Payer: United Healthcare Medicaid |
$23.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.60
|
| Rate for Payer: United Healthcare PPO |
$726.75
|
| Rate for Payer: WEA Trust Commercial |
$532.95
|
| Rate for Payer: Wellcare Medicare |
$23.60
|
| Rate for Payer: WMAP Medicaid |
$23.14
|
| Rate for Payer: WPS Commercial |
$717.74
|
|
