|
OT Ultrasound Charges
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
CPT 97035 GO
|
| Hospital Charge Code |
2468809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
OT Ultrasound Charges
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
CPT 97035 GO
|
| Hospital Charge Code |
2468809
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: United Healthcare PPO |
$124.02
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
OT Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 97014
|
| Hospital Charge Code |
5254608
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
OT Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 97014
|
| Hospital Charge Code |
5254608
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.01 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: United Healthcare PPO |
$123.24
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
OT Wheelchair Management Charges
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97542 GO
|
| Hospital Charge Code |
750928
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$64.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$139.15
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$139.15
|
| Rate for Payer: The Alliance Commercial |
$115.96
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
OT Wheelchair Management Charges
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97542 GO
|
| Hospital Charge Code |
750928
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Outback Re-Entry Catheter
|
Facility
|
OP
|
$13,475.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
4534609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,923.92 |
| Max. Negotiated Rate |
$12,892.88 |
| Rate for Payer: Aetna Commercial |
$12,612.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,052.04
|
| Rate for Payer: Aetna Managed Medicare |
$3,923.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,109.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,007.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,726.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,427.42
|
| Rate for Payer: Cash Price |
$4,042.50
|
| Rate for Payer: Cigna Commercial |
$12,892.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,842.45
|
| Rate for Payer: Health EOS Commercial |
$12,472.46
|
| Rate for Payer: HFN Commercial |
$12,892.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,510.50
|
| Rate for Payer: Multiplan Commercial |
$11,211.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,408.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,892.88
|
| Rate for Payer: Quartz Beloit One Network |
$6,866.86
|
| Rate for Payer: Quartz Commercial |
$9,109.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8,408.40
|
| Rate for Payer: The Alliance Commercial |
$7,007.00
|
| Rate for Payer: WEA Trust Commercial |
$7,707.70
|
| Rate for Payer: WPS Commercial |
$10,379.79
|
|
|
Outback Re-Entry Catheter
|
Facility
|
IP
|
$13,475.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
4534609
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,866.86 |
| Max. Negotiated Rate |
$12,892.88 |
| Rate for Payer: Aetna Commercial |
$12,612.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,052.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,427.42
|
| Rate for Payer: Cash Price |
$4,042.50
|
| Rate for Payer: Cigna Commercial |
$12,892.88
|
| Rate for Payer: Health EOS Commercial |
$12,472.46
|
| Rate for Payer: HFN Commercial |
$12,892.88
|
| Rate for Payer: Multiplan Commercial |
$11,211.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,892.88
|
| Rate for Payer: Quartz Beloit One Network |
$6,866.86
|
| Rate for Payer: Quartz Commercial |
$8,408.40
|
| Rate for Payer: WEA Trust Commercial |
$7,707.70
|
| Rate for Payer: WPS Commercial |
$10,379.79
|
|
|
OUTFLOW TUBE SET HYSTEROSCIOPIC TRUCLEAR LEGACY FLUID MANAGEMENT 7209823
|
Facility
|
OP
|
$500.00
|
|
| Hospital Charge Code |
5797666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$478.40 |
| Rate for Payer: Aetna Commercial |
$468.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$447.20
|
| Rate for Payer: Aetna Managed Medicare |
$145.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$338.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$260.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$249.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.60
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$478.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$291.00
|
| Rate for Payer: Health EOS Commercial |
$462.80
|
| Rate for Payer: HFN Commercial |
$478.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$390.00
|
| Rate for Payer: Multiplan Commercial |
$416.00
|
| Rate for Payer: NAPHCARE Commercial |
$312.00
|
| Rate for Payer: Preferred Network Access Commercial |
$478.40
|
| Rate for Payer: Quartz Beloit One Network |
$254.80
|
| Rate for Payer: Quartz Commercial |
$338.00
|
| Rate for Payer: Quartz Medicare Advantage |
$312.00
|
| Rate for Payer: The Alliance Commercial |
$260.00
|
| Rate for Payer: WEA Trust Commercial |
$286.00
|
| Rate for Payer: WPS Commercial |
$385.15
|
|
|
OUTFLOW TUBE SET HYSTEROSCIOPIC TRUCLEAR LEGACY FLUID MANAGEMENT 7209823
|
Facility
|
IP
|
$500.00
|
|
| Hospital Charge Code |
5797666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$254.80 |
| Max. Negotiated Rate |
$478.40 |
| Rate for Payer: Aetna Commercial |
$468.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$447.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$275.60
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$478.40
|
| Rate for Payer: Health EOS Commercial |
$462.80
|
| Rate for Payer: HFN Commercial |
$478.40
|
| Rate for Payer: Multiplan Commercial |
$416.00
|
| Rate for Payer: Preferred Network Access Commercial |
$478.40
|
| Rate for Payer: Quartz Beloit One Network |
$254.80
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$286.00
|
| Rate for Payer: WPS Commercial |
$385.15
|
|
|
Outpatient IM/SQ Injections
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4602731
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Outpatient IM/SQ Injections
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4602731
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
Ova and Parasites
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$136.66
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Ova and Parasites
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$9.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Anthem Medicare Advantage |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.26
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.26
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$13.88
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$148.04
|
| Rate for Payer: Quartz Medicare Advantage |
$9.26
|
| Rate for Payer: The Alliance Commercial |
$37.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.26
|
| Rate for Payer: United Healthcare PPO |
$170.82
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: Wellcare Medicare |
$9.26
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Ova and Parasites
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
633911
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$216.37 |
| Rate for Payer: Aetna Commercial |
$216.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$9.26
|
| Rate for Payer: Anthem Medicare Advantage |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.26
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$216.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.26
|
| Rate for Payer: Health EOS Commercial |
$207.26
|
| Rate for Payer: HFN Commercial |
$216.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$13.88
|
| Rate for Payer: Preferred Network Access Commercial |
$216.37
|
| Rate for Payer: Quartz Beloit One Network |
$100.21
|
| Rate for Payer: Quartz Commercial |
$129.82
|
| Rate for Payer: Quartz Medicare Advantage |
$9.26
|
| Rate for Payer: The Alliance Commercial |
$36.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.26
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$40.73
|
|
|
Ova and Parasites Smears 87177PP
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
3190193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$9.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Anthem Medicare Advantage |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.26
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.26
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$13.88
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$71.66
|
| Rate for Payer: Quartz Medicare Advantage |
$9.26
|
| Rate for Payer: The Alliance Commercial |
$37.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.26
|
| Rate for Payer: United Healthcare PPO |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: Wellcare Medicare |
$9.26
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
Ova and Parasites Smears 87177PP
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
3190193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.02 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$66.14
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
Ova & Parasite, Quest Confirmation
|
Facility
|
OP
|
$13.30
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
983349
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.78 |
| Max. Negotiated Rate |
$37.02 |
| Rate for Payer: Aetna Commercial |
$12.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11.90
|
| Rate for Payer: Aetna Managed Medicare |
$9.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Anthem Medicare Advantage |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.26
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$12.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.26
|
| Rate for Payer: Health EOS Commercial |
$12.31
|
| Rate for Payer: HFN Commercial |
$12.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.88
|
| Rate for Payer: Preferred Network Access Commercial |
$12.73
|
| Rate for Payer: Quartz Beloit One Network |
$6.78
|
| Rate for Payer: Quartz Commercial |
$8.99
|
| Rate for Payer: Quartz Medicare Advantage |
$9.26
|
| Rate for Payer: The Alliance Commercial |
$37.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.26
|
| Rate for Payer: United Healthcare PPO |
$10.37
|
| Rate for Payer: WEA Trust Commercial |
$7.61
|
| Rate for Payer: Wellcare Medicare |
$9.26
|
| Rate for Payer: WPS Commercial |
$10.24
|
|
|
Ova & Parasite, Quest Confirmation
|
Facility
|
IP
|
$13.30
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
983349
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.78 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna Commercial |
$12.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.33
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$12.73
|
| Rate for Payer: Health EOS Commercial |
$12.31
|
| Rate for Payer: HFN Commercial |
$12.73
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: Preferred Network Access Commercial |
$12.73
|
| Rate for Payer: Quartz Beloit One Network |
$6.78
|
| Rate for Payer: Quartz Commercial |
$8.30
|
| Rate for Payer: WEA Trust Commercial |
$7.61
|
| Rate for Payer: WPS Commercial |
$10.24
|
|
|
Ova & Parasite, Quest Confirmation
|
Professional
|
Both
|
$13.30
|
|
|
Service Code
|
CPT 87177
|
| Hospital Charge Code |
983349
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$40.73 |
| Rate for Payer: Aetna Commercial |
$13.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11.90
|
| Rate for Payer: Aetna Managed Medicare |
$9.26
|
| Rate for Payer: Anthem Medicare Advantage |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.26
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: Cigna Commercial |
$13.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.26
|
| Rate for Payer: Health EOS Commercial |
$12.59
|
| Rate for Payer: HFN Commercial |
$13.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$11.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.88
|
| Rate for Payer: Preferred Network Access Commercial |
$13.14
|
| Rate for Payer: Quartz Beloit One Network |
$6.09
|
| Rate for Payer: Quartz Commercial |
$7.88
|
| Rate for Payer: Quartz Medicare Advantage |
$9.26
|
| Rate for Payer: The Alliance Commercial |
$36.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.26
|
| Rate for Payer: WEA Trust Commercial |
$7.61
|
| Rate for Payer: WPS Commercial |
$40.73
|
|
|
OVARIAN CYSTECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960299
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
OVARIAN CYSTECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960299
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL
|
Facility
|
OP
|
$21,058.09
|
|
|
Service Code
|
CPT 58925
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$21,058.09 |
| Rate for Payer: Aetna Managed Medicare |
$5,264.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,264.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,264.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,264.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,264.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,584.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,264.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,264.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,264.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,264.52
|
| Rate for Payer: NAPHCARE Commercial |
$7,896.78
|
| Rate for Payer: Quartz Medicare Advantage |
$5,264.52
|
| Rate for Payer: The Alliance Commercial |
$21,058.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,264.52
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$5,264.52
|
|
|
OVERDRILL 2.7MM X 122MM AO STRYKER 703897
|
Facility
|
OP
|
$1,346.00
|
|
| Hospital Charge Code |
5685725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$391.96 |
| Max. Negotiated Rate |
$1,287.85 |
| Rate for Payer: Aetna Commercial |
$1,259.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,203.86
|
| Rate for Payer: Aetna Managed Medicare |
$391.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$909.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$699.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$671.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$741.92
|
| Rate for Payer: Cash Price |
$403.80
|
| Rate for Payer: Cigna Commercial |
$1,287.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$783.37
|
| Rate for Payer: Health EOS Commercial |
$1,245.86
|
| Rate for Payer: HFN Commercial |
$1,287.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,049.88
|
| Rate for Payer: Multiplan Commercial |
$1,119.87
|
| Rate for Payer: NAPHCARE Commercial |
$839.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,287.85
|
| Rate for Payer: Quartz Beloit One Network |
$685.92
|
| Rate for Payer: Quartz Commercial |
$909.90
|
| Rate for Payer: Quartz Medicare Advantage |
$839.90
|
| Rate for Payer: The Alliance Commercial |
$699.92
|
| Rate for Payer: WEA Trust Commercial |
$769.91
|
| Rate for Payer: WPS Commercial |
$1,036.82
|
|
|
OVERDRILL 2.7MM X 122MM AO STRYKER 703897
|
Facility
|
IP
|
$1,346.00
|
|
| Hospital Charge Code |
5685725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$685.92 |
| Max. Negotiated Rate |
$1,287.85 |
| Rate for Payer: Aetna Commercial |
$1,259.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,203.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$741.92
|
| Rate for Payer: Cash Price |
$403.80
|
| Rate for Payer: Cigna Commercial |
$1,287.85
|
| Rate for Payer: Health EOS Commercial |
$1,245.86
|
| Rate for Payer: HFN Commercial |
$1,287.85
|
| Rate for Payer: Multiplan Commercial |
$1,119.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,287.85
|
| Rate for Payer: Quartz Beloit One Network |
$685.92
|
| Rate for Payer: Quartz Commercial |
$839.90
|
| Rate for Payer: WEA Trust Commercial |
$769.91
|
| Rate for Payer: WPS Commercial |
$1,036.82
|
|
