|
PRO-DENSE INJECTABLE CALCIUM SULFATE CALCIUM PHOSPHATE 5CC 87SR0050
|
Facility
|
OP
|
$14,472.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6240148
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,052.17 |
| Max. Negotiated Rate |
$57,888.20 |
| Rate for Payer: Aetna Commercial |
$13,024.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,445.96
|
| Rate for Payer: Aetna Managed Medicare |
$4,052.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,406.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,236.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,946.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,670.19
|
| Rate for Payer: Cash Price |
$4,341.62
|
| Rate for Payer: Cigna Commercial |
$13,314.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,098.56
|
| Rate for Payer: Health EOS Commercial |
$12,880.12
|
| Rate for Payer: HFN Commercial |
$13,314.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,854.04
|
| Rate for Payer: Multiplan Commercial |
$11,577.64
|
| Rate for Payer: NAPHCARE Commercial |
$8,683.23
|
| Rate for Payer: Preferred Network Access Commercial |
$13,314.29
|
| Rate for Payer: Quartz Beloit One Network |
$7,091.30
|
| Rate for Payer: Quartz Commercial |
$9,406.83
|
| Rate for Payer: Quartz Medicare Advantage |
$8,683.23
|
| Rate for Payer: The Alliance Commercial |
$57,888.20
|
| Rate for Payer: WEA Trust Commercial |
$7,959.63
|
| Rate for Payer: WPS Commercial |
$10,719.45
|
|
|
PRO-DENSE INJECTABLE CALCIUM SULFATE CALCIUM PHOSPHATE 5CC 87SR0050
|
Facility
|
IP
|
$14,472.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6240148
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,091.30 |
| Max. Negotiated Rate |
$13,314.29 |
| Rate for Payer: Aetna Commercial |
$13,024.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,445.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,670.19
|
| Rate for Payer: Cash Price |
$4,341.62
|
| Rate for Payer: Cigna Commercial |
$13,314.29
|
| Rate for Payer: Health EOS Commercial |
$12,880.12
|
| Rate for Payer: HFN Commercial |
$13,314.29
|
| Rate for Payer: Multiplan Commercial |
$11,577.64
|
| Rate for Payer: NAPHCARE Commercial |
$8,683.23
|
| Rate for Payer: Preferred Network Access Commercial |
$13,314.29
|
| Rate for Payer: Quartz Beloit One Network |
$7,091.30
|
| Rate for Payer: Quartz Commercial |
$8,683.23
|
| Rate for Payer: WEA Trust Commercial |
$7,959.63
|
| Rate for Payer: WPS Commercial |
$10,719.45
|
|
|
Profess Serv,Supervis Of Prep/Provisn Of Antigen, Allergen Immthrpy
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
CPT 95145
|
| Hospital Charge Code |
1188811
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$115.68 |
| Rate for Payer: Aetna Commercial |
$33.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$33.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.00
|
| Rate for Payer: Health EOS Commercial |
$31.85
|
| Rate for Payer: HFN Commercial |
$33.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.68
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: Preferred Network Access Commercial |
$33.25
|
| Rate for Payer: Quartz Beloit One Network |
$15.40
|
| Rate for Payer: Quartz Commercial |
$19.95
|
| Rate for Payer: The Alliance Commercial |
$17.50
|
| Rate for Payer: United Healthcare Medicaid |
$19.99
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
PROFILE FORM
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2971441
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
PROFILE FORM
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2971441
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
PROFILE FORMS STAXI-2
|
Facility
|
IP
|
$1,408.00
|
|
| Hospital Charge Code |
2972253
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$689.92 |
| Max. Negotiated Rate |
$1,295.36 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$844.80
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
PROFILE FORMS STAXI-2
|
Facility
|
OP
|
$1,408.00
|
|
| Hospital Charge Code |
2972253
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$394.24 |
| Max. Negotiated Rate |
$5,632.00 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Aetna Managed Medicare |
$394.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$915.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$675.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$787.92
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,056.00
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$915.20
|
| Rate for Payer: Quartz Medicare Advantage |
$844.80
|
| Rate for Payer: The Alliance Commercial |
$5,632.00
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
PROF & INST - SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM ADL 100SQ CM 15278
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 15278
|
| Hospital Charge Code |
6149815
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.42 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.00
|
| Rate for Payer: Health EOS Commercial |
$186.55
|
| Rate for Payer: HFN Commercial |
$194.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$183.84
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$194.75
|
| Rate for Payer: Quartz Beloit One Network |
$90.20
|
| Rate for Payer: Quartz Commercial |
$116.85
|
| Rate for Payer: The Alliance Commercial |
$102.50
|
| Rate for Payer: United Healthcare Medicaid |
$62.42
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
Progesterone, LC/MS/MS
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
4614608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$80.96 |
| Rate for Payer: Aetna Commercial |
$79.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.64
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$80.96
|
| Rate for Payer: Health EOS Commercial |
$78.32
|
| Rate for Payer: HFN Commercial |
$80.96
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$80.96
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$52.80
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
Progesterone, LC/MS/MS
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
4614608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$83.44 |
| Rate for Payer: Aetna Commercial |
$79.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Aetna Managed Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.63
|
| Rate for Payer: Anthem Medicaid |
$21.55
|
| Rate for Payer: Anthem Medicare Advantage |
$20.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.86
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$80.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.24
|
| Rate for Payer: Dean Health Medicaid |
$21.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.86
|
| Rate for Payer: Health EOS Commercial |
$78.32
|
| Rate for Payer: HFN Commercial |
$80.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.86
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.86
|
| Rate for Payer: Managed Health Services Medicaid |
$22.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.86
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.86
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.29
|
| Rate for Payer: Preferred Network Access Commercial |
$80.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.55
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$57.20
|
| Rate for Payer: Quartz Medicare Advantage |
$20.86
|
| Rate for Payer: The Alliance Commercial |
$83.44
|
| Rate for Payer: United Healthcare Medicaid |
$21.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.86
|
| Rate for Payer: United Healthcare PPO |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: Wellcare Medicare |
$20.86
|
| Rate for Payer: WMAP Medicaid |
$21.55
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
Progesterone, LC/MS/MS
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
4614608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$83.60 |
| Rate for Payer: Aetna Commercial |
$83.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$83.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.80
|
| Rate for Payer: Health EOS Commercial |
$80.08
|
| Rate for Payer: HFN Commercial |
$83.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.64
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: Preferred Network Access Commercial |
$83.60
|
| Rate for Payer: Quartz Beloit One Network |
$38.72
|
| Rate for Payer: Quartz Commercial |
$50.16
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
|
Progesterone Level
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
633808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$143.57 |
| Max. Negotiated Rate |
$269.56 |
| Rate for Payer: Aetna Commercial |
$263.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.29
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$269.56
|
| Rate for Payer: Health EOS Commercial |
$260.77
|
| Rate for Payer: HFN Commercial |
$269.56
|
| Rate for Payer: Multiplan Commercial |
$234.40
|
| Rate for Payer: NAPHCARE Commercial |
$175.80
|
| Rate for Payer: Preferred Network Access Commercial |
$269.56
|
| Rate for Payer: Quartz Beloit One Network |
$143.57
|
| Rate for Payer: Quartz Commercial |
$175.80
|
| Rate for Payer: WEA Trust Commercial |
$161.15
|
| Rate for Payer: WPS Commercial |
$217.03
|
|
|
Progesterone Level
|
Professional
|
Both
|
$293.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
633808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.64 |
| Max. Negotiated Rate |
$278.35 |
| Rate for Payer: Aetna Commercial |
$278.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.98
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$278.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$146.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.80
|
| Rate for Payer: Health EOS Commercial |
$266.63
|
| Rate for Payer: HFN Commercial |
$278.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.64
|
| Rate for Payer: Multiplan Commercial |
$234.40
|
| Rate for Payer: Preferred Network Access Commercial |
$278.35
|
| Rate for Payer: Quartz Beloit One Network |
$128.92
|
| Rate for Payer: Quartz Commercial |
$167.01
|
| Rate for Payer: The Alliance Commercial |
$146.50
|
| Rate for Payer: WEA Trust Commercial |
$161.15
|
| Rate for Payer: WPS Commercial |
$217.03
|
|
|
Progesterone Level
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
633808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$269.56 |
| Rate for Payer: Aetna Commercial |
$263.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.98
|
| Rate for Payer: Aetna Managed Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.63
|
| Rate for Payer: Anthem Medicaid |
$21.55
|
| Rate for Payer: Anthem Medicare Advantage |
$20.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.86
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$269.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.96
|
| Rate for Payer: Dean Health Medicaid |
$21.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.86
|
| Rate for Payer: Health EOS Commercial |
$260.77
|
| Rate for Payer: HFN Commercial |
$269.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.86
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.86
|
| Rate for Payer: Managed Health Services Medicaid |
$22.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.86
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.86
|
| Rate for Payer: Multiplan Commercial |
$234.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.29
|
| Rate for Payer: Preferred Network Access Commercial |
$269.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.55
|
| Rate for Payer: Quartz Beloit One Network |
$143.57
|
| Rate for Payer: Quartz Commercial |
$190.45
|
| Rate for Payer: Quartz Medicare Advantage |
$20.86
|
| Rate for Payer: The Alliance Commercial |
$83.44
|
| Rate for Payer: United Healthcare Medicaid |
$21.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.86
|
| Rate for Payer: United Healthcare PPO |
$219.75
|
| Rate for Payer: WEA Trust Commercial |
$161.15
|
| Rate for Payer: Wellcare Medicare |
$20.86
|
| Rate for Payer: WMAP Medicaid |
$21.55
|
| Rate for Payer: WPS Commercial |
$217.03
|
|
|
PROGRAMMER INTERSTIM SMART (RECHARGE FREE) TH90P01
|
Facility
|
OP
|
$9,820.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
5603550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,749.60 |
| Max. Negotiated Rate |
$39,280.00 |
| Rate for Payer: Aetna Commercial |
$8,838.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,445.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,749.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,383.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,910.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,204.60
|
| Rate for Payer: Cash Price |
$2,946.00
|
| Rate for Payer: Cigna Commercial |
$9,034.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,495.27
|
| Rate for Payer: Health EOS Commercial |
$8,739.80
|
| Rate for Payer: HFN Commercial |
$9,034.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,365.00
|
| Rate for Payer: Multiplan Commercial |
$7,856.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,892.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,034.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,811.80
|
| Rate for Payer: Quartz Commercial |
$6,383.00
|
| Rate for Payer: Quartz Medicare Advantage |
$5,892.00
|
| Rate for Payer: The Alliance Commercial |
$39,280.00
|
| Rate for Payer: WEA Trust Commercial |
$5,401.00
|
| Rate for Payer: WPS Commercial |
$7,273.67
|
|
|
PROGRAMMER INTERSTIM SMART (RECHARGE FREE) TH90P01
|
Facility
|
IP
|
$9,820.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
5603550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,811.80 |
| Max. Negotiated Rate |
$9,034.40 |
| Rate for Payer: Aetna Commercial |
$8,838.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,445.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,204.60
|
| Rate for Payer: Cash Price |
$2,946.00
|
| Rate for Payer: Cigna Commercial |
$9,034.40
|
| Rate for Payer: Health EOS Commercial |
$8,739.80
|
| Rate for Payer: HFN Commercial |
$9,034.40
|
| Rate for Payer: Multiplan Commercial |
$7,856.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,892.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,034.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,811.80
|
| Rate for Payer: Quartz Commercial |
$5,892.00
|
| Rate for Payer: WEA Trust Commercial |
$5,401.00
|
| Rate for Payer: WPS Commercial |
$7,273.67
|
|
|
PROGRAMMER INTERSTIM X (RECHARGE FREE) TH90Q01
|
Facility
|
IP
|
$7,741.00
|
|
| Hospital Charge Code |
6049664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,793.09 |
| Max. Negotiated Rate |
$7,121.72 |
| Rate for Payer: Aetna Commercial |
$6,966.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,657.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,102.73
|
| Rate for Payer: Cash Price |
$2,322.30
|
| Rate for Payer: Cigna Commercial |
$7,121.72
|
| Rate for Payer: Health EOS Commercial |
$6,889.49
|
| Rate for Payer: HFN Commercial |
$7,121.72
|
| Rate for Payer: Multiplan Commercial |
$6,192.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,644.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,121.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,793.09
|
| Rate for Payer: Quartz Commercial |
$4,644.60
|
| Rate for Payer: WEA Trust Commercial |
$4,257.55
|
| Rate for Payer: WPS Commercial |
$5,733.76
|
|
|
PROGRAMMER INTERSTIM X (RECHARGE FREE) TH90Q01
|
Facility
|
OP
|
$7,741.00
|
|
| Hospital Charge Code |
6049664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,167.48 |
| Max. Negotiated Rate |
$30,964.00 |
| Rate for Payer: Aetna Commercial |
$6,966.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,657.26
|
| Rate for Payer: Aetna Managed Medicare |
$2,167.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,031.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,870.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,715.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,102.73
|
| Rate for Payer: Cash Price |
$2,322.30
|
| Rate for Payer: Cigna Commercial |
$7,121.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,331.86
|
| Rate for Payer: Health EOS Commercial |
$6,889.49
|
| Rate for Payer: HFN Commercial |
$7,121.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,805.75
|
| Rate for Payer: Multiplan Commercial |
$6,192.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,644.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,121.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,793.09
|
| Rate for Payer: Quartz Commercial |
$5,031.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,644.60
|
| Rate for Payer: The Alliance Commercial |
$30,964.00
|
| Rate for Payer: WEA Trust Commercial |
$4,257.55
|
| Rate for Payer: WPS Commercial |
$5,733.76
|
|
|
Programming Device Evaluation 93279
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
CPT 93279
|
| Hospital Charge Code |
4586628
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$226.20 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.80
|
| Rate for Payer: Health EOS Commercial |
$57.33
|
| Rate for Payer: HFN Commercial |
$59.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$226.20
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$59.85
|
| Rate for Payer: Quartz Beloit One Network |
$27.72
|
| Rate for Payer: Quartz Commercial |
$35.91
|
| Rate for Payer: The Alliance Commercial |
$31.50
|
| Rate for Payer: United Healthcare Medicaid |
$41.78
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Programming Device Evaluation 9327926
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
CPT 93279 26
|
| Hospital Charge Code |
3328179
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$109.78 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.80
|
| Rate for Payer: Health EOS Commercial |
$57.33
|
| Rate for Payer: HFN Commercial |
$59.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$59.85
|
| Rate for Payer: Quartz Beloit One Network |
$27.72
|
| Rate for Payer: Quartz Commercial |
$35.91
|
| Rate for Payer: The Alliance Commercial |
$31.50
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Programming Device Evaluation, Dual Lead 9328326
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
CPT 93283 26
|
| Hospital Charge Code |
4514729
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$196.48 |
| Max. Negotiated Rate |
$665.00 |
| Rate for Payer: Aetna Commercial |
$665.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$665.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$350.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$420.00
|
| Rate for Payer: Health EOS Commercial |
$637.00
|
| Rate for Payer: HFN Commercial |
$665.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.48
|
| Rate for Payer: Multiplan Commercial |
$560.00
|
| Rate for Payer: Preferred Network Access Commercial |
$665.00
|
| Rate for Payer: Quartz Beloit One Network |
$308.00
|
| Rate for Payer: Quartz Commercial |
$399.00
|
| Rate for Payer: The Alliance Commercial |
$350.00
|
| Rate for Payer: WEA Trust Commercial |
$385.00
|
| Rate for Payer: WPS Commercial |
$518.49
|
|
|
Programming Device Evaluation, Dual Lead Implantable Cardioverter-Defibrillator
|
Professional
|
Both
|
$701.00
|
|
|
Service Code
|
CPT 93283
|
| Hospital Charge Code |
1190892
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$665.95 |
| Rate for Payer: Aetna Commercial |
$665.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.86
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$665.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$65.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$420.60
|
| Rate for Payer: Health EOS Commercial |
$637.91
|
| Rate for Payer: HFN Commercial |
$665.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$333.76
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: Preferred Network Access Commercial |
$665.95
|
| Rate for Payer: Quartz Beloit One Network |
$308.44
|
| Rate for Payer: Quartz Commercial |
$399.57
|
| Rate for Payer: The Alliance Commercial |
$350.50
|
| Rate for Payer: United Healthcare Medicaid |
$65.26
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
Programming Device Evaluation, Implantable Loop Recorder System
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
CPT 93285
|
| Hospital Charge Code |
1190894
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.35 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.06
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: United Healthcare Medicaid |
$34.35
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Programming Device Evaluation, Multiple Lead Implantable Cardioverter-Defibrillator
|
Professional
|
Both
|
$619.00
|
|
|
Service Code
|
CPT 93284
|
| Hospital Charge Code |
1190893
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$588.05 |
| Rate for Payer: Aetna Commercial |
$588.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$588.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$371.40
|
| Rate for Payer: Health EOS Commercial |
$563.29
|
| Rate for Payer: HFN Commercial |
$588.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$361.15
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: Preferred Network Access Commercial |
$588.05
|
| Rate for Payer: Quartz Beloit One Network |
$272.36
|
| Rate for Payer: Quartz Commercial |
$352.83
|
| Rate for Payer: The Alliance Commercial |
$309.50
|
| Rate for Payer: United Healthcare Medicaid |
$54.34
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
Programming Device Evaluation, Single Lead Implantable Cardioverter-Defibrillator
|
Professional
|
Both
|
$912.00
|
|
|
Service Code
|
CPT 93282
|
| Hospital Charge Code |
1190891
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.52 |
| Max. Negotiated Rate |
$866.40 |
| Rate for Payer: Aetna Commercial |
$866.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$784.32
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cigna Commercial |
$866.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$547.20
|
| Rate for Payer: Health EOS Commercial |
$829.92
|
| Rate for Payer: HFN Commercial |
$866.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$271.28
|
| Rate for Payer: Multiplan Commercial |
$729.60
|
| Rate for Payer: Preferred Network Access Commercial |
$866.40
|
| Rate for Payer: Quartz Beloit One Network |
$401.28
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: United Healthcare Medicaid |
$53.52
|
| Rate for Payer: WEA Trust Commercial |
$501.60
|
| Rate for Payer: WPS Commercial |
$675.52
|
|
