|
SCISSOR GRIP HARMONIC ACE 5mm ACE14S
|
Facility
|
IP
|
$5,910.00
|
|
| Hospital Charge Code |
2974014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,895.90 |
| Max. Negotiated Rate |
$5,437.20 |
| Rate for Payer: Aetna Commercial |
$5,319.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,082.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,132.30
|
| Rate for Payer: Cash Price |
$1,773.00
|
| Rate for Payer: Cigna Commercial |
$5,437.20
|
| Rate for Payer: Health EOS Commercial |
$5,259.90
|
| Rate for Payer: HFN Commercial |
$5,437.20
|
| Rate for Payer: Multiplan Commercial |
$4,728.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,546.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,437.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,895.90
|
| Rate for Payer: Quartz Commercial |
$3,546.00
|
| Rate for Payer: WEA Trust Commercial |
$3,250.50
|
| Rate for Payer: WPS Commercial |
$4,377.54
|
|
|
SCISSORS ENDO BIPOLAR 5MM 5DCS
|
Facility
|
OP
|
$958.00
|
|
| Hospital Charge Code |
3633524
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.24 |
| Max. Negotiated Rate |
$3,832.00 |
| Rate for Payer: Aetna Commercial |
$862.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$823.88
|
| Rate for Payer: Aetna Managed Medicare |
$268.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$622.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$459.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$507.74
|
| Rate for Payer: Cash Price |
$287.40
|
| Rate for Payer: Cigna Commercial |
$881.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.10
|
| Rate for Payer: Health EOS Commercial |
$852.62
|
| Rate for Payer: HFN Commercial |
$881.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$718.50
|
| Rate for Payer: Multiplan Commercial |
$766.40
|
| Rate for Payer: NAPHCARE Commercial |
$574.80
|
| Rate for Payer: Preferred Network Access Commercial |
$881.36
|
| Rate for Payer: Quartz Beloit One Network |
$469.42
|
| Rate for Payer: Quartz Commercial |
$622.70
|
| Rate for Payer: Quartz Medicare Advantage |
$574.80
|
| Rate for Payer: The Alliance Commercial |
$3,832.00
|
| Rate for Payer: WEA Trust Commercial |
$526.90
|
| Rate for Payer: WPS Commercial |
$709.59
|
|
|
SCISSORS ENDO BIPOLAR 5MM 5DCS
|
Facility
|
IP
|
$958.00
|
|
| Hospital Charge Code |
3633524
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.42 |
| Max. Negotiated Rate |
$881.36 |
| Rate for Payer: Aetna Commercial |
$862.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$823.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$507.74
|
| Rate for Payer: Cash Price |
$287.40
|
| Rate for Payer: Cigna Commercial |
$881.36
|
| Rate for Payer: Health EOS Commercial |
$852.62
|
| Rate for Payer: HFN Commercial |
$881.36
|
| Rate for Payer: Multiplan Commercial |
$766.40
|
| Rate for Payer: NAPHCARE Commercial |
$574.80
|
| Rate for Payer: Preferred Network Access Commercial |
$881.36
|
| Rate for Payer: Quartz Beloit One Network |
$469.42
|
| Rate for Payer: Quartz Commercial |
$574.80
|
| Rate for Payer: WEA Trust Commercial |
$526.90
|
| Rate for Payer: WPS Commercial |
$709.59
|
|
|
SCISSORS OSTOMY CRVD BLNT/BLNT
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2963460
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Aetna Managed Medicare |
$47.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.69
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.25
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$111.15
|
| Rate for Payer: Quartz Medicare Advantage |
$102.60
|
| Rate for Payer: The Alliance Commercial |
$684.00
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
SCISSORS OSTOMY CRVD BLNT/BLNT
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2963460
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$157.32 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$102.60
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
SCISSORS SHAFT 34CM MINI 5MM
|
Facility
|
OP
|
$1,552.00
|
|
| Hospital Charge Code |
2962918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$434.56 |
| Max. Negotiated Rate |
$6,208.00 |
| Rate for Payer: Aetna Commercial |
$1,396.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,334.72
|
| Rate for Payer: Aetna Managed Medicare |
$434.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,008.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$776.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$744.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$822.56
|
| Rate for Payer: Cash Price |
$465.60
|
| Rate for Payer: Cigna Commercial |
$1,427.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$868.50
|
| Rate for Payer: Health EOS Commercial |
$1,381.28
|
| Rate for Payer: HFN Commercial |
$1,427.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,164.00
|
| Rate for Payer: Multiplan Commercial |
$1,241.60
|
| Rate for Payer: NAPHCARE Commercial |
$931.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,427.84
|
| Rate for Payer: Quartz Beloit One Network |
$760.48
|
| Rate for Payer: Quartz Commercial |
$1,008.80
|
| Rate for Payer: Quartz Medicare Advantage |
$931.20
|
| Rate for Payer: The Alliance Commercial |
$6,208.00
|
| Rate for Payer: WEA Trust Commercial |
$853.60
|
| Rate for Payer: WPS Commercial |
$1,149.57
|
|
|
SCISSORS SHAFT 34CM MINI 5MM
|
Facility
|
IP
|
$1,552.00
|
|
| Hospital Charge Code |
2962918
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$760.48 |
| Max. Negotiated Rate |
$1,427.84 |
| Rate for Payer: Aetna Commercial |
$1,396.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,334.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$822.56
|
| Rate for Payer: Cash Price |
$465.60
|
| Rate for Payer: Cigna Commercial |
$1,427.84
|
| Rate for Payer: Health EOS Commercial |
$1,381.28
|
| Rate for Payer: HFN Commercial |
$1,427.84
|
| Rate for Payer: Multiplan Commercial |
$1,241.60
|
| Rate for Payer: NAPHCARE Commercial |
$931.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,427.84
|
| Rate for Payer: Quartz Beloit One Network |
$760.48
|
| Rate for Payer: Quartz Commercial |
$931.20
|
| Rate for Payer: WEA Trust Commercial |
$853.60
|
| Rate for Payer: WPS Commercial |
$1,149.57
|
|
|
Scl 70 Antibody
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
978062
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.29 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: HFN Commercial |
$187.15
|
| Rate for Payer: Health EOS Commercial |
$179.27
|
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.29
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: Preferred Network Access Commercial |
$187.15
|
| Rate for Payer: Quartz Beloit One Network |
$86.68
|
| Rate for Payer: Quartz Commercial |
$112.29
|
| Rate for Payer: The Alliance Commercial |
$98.50
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Scl 70 Antibody
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
978062
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Anthem Medicaid |
$18.53
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.24
|
| Rate for Payer: Dean Health Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Managed Health Services Medicaid |
$19.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$26.90
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.53
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$128.05
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$71.72
|
| Rate for Payer: United Healthcare Medicaid |
$18.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Healthcare PPO |
$147.75
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: WMAP Medicaid |
$18.53
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Scl 70 Antibody
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
978062
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$118.20
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
|
Scl 70 to TheraTest
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2778818
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$63.29 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: HFN Commercial |
$51.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.29
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Scl 70 to TheraTest
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2778818
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$71.72 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Anthem Medicaid |
$18.53
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Dean Health Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Managed Health Services Medicaid |
$19.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.90
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.53
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$71.72
|
| Rate for Payer: United Healthcare Medicaid |
$18.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Healthcare PPO |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: WMAP Medicaid |
$18.53
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Scl 70 to TheraTest
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2778818
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Scleroderma Antibody (Scl 70)
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942854
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Scleroderma Antibody (Scl 70)
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942854
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Anthem Medicaid |
$18.53
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.54
|
| Rate for Payer: Dean Health Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Managed Health Services Medicaid |
$19.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.90
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.53
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$71.72
|
| Rate for Payer: United Healthcare Medicaid |
$18.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Healthcare PPO |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: WMAP Medicaid |
$18.53
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
Scleroderma Antibody (Scl 70)
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942854
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.29 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.40
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: HFN Commercial |
$231.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.29
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: The Alliance Commercial |
$122.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SCLEROTHERAPY
|
Facility
|
IP
|
$888.00
|
|
| Hospital Charge Code |
2960563
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$435.12 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$532.80
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
SCLEROTHERAPY
|
Facility
|
OP
|
$888.00
|
|
| Hospital Charge Code |
2960563
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$248.64 |
| Max. Negotiated Rate |
$3,552.00 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Aetna Managed Medicare |
$248.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.92
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.00
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: Quartz Medicare Advantage |
$532.80
|
| Rate for Payer: The Alliance Commercial |
$3,552.00
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
SCOPE NANONEEDLE 125MM AR-3210-0043
|
Facility
|
OP
|
$3,724.00
|
|
| Hospital Charge Code |
6234120
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.72 |
| Max. Negotiated Rate |
$14,896.00 |
| Rate for Payer: Aetna Commercial |
$3,351.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,202.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,042.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,420.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,862.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,787.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.72
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,426.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,083.95
|
| Rate for Payer: Health EOS Commercial |
$3,314.36
|
| Rate for Payer: HFN Commercial |
$3,426.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,793.00
|
| Rate for Payer: Multiplan Commercial |
$2,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,234.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,426.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.76
|
| Rate for Payer: Quartz Commercial |
$2,420.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,234.40
|
| Rate for Payer: The Alliance Commercial |
$14,896.00
|
| Rate for Payer: WEA Trust Commercial |
$2,048.20
|
| Rate for Payer: WPS Commercial |
$2,758.37
|
|
|
SCOPE NANONEEDLE 125MM AR-3210-0043
|
Facility
|
IP
|
$3,724.00
|
|
| Hospital Charge Code |
6234120
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,824.76 |
| Max. Negotiated Rate |
$3,426.08 |
| Rate for Payer: Aetna Commercial |
$3,351.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,202.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,973.72
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,426.08
|
| Rate for Payer: Health EOS Commercial |
$3,314.36
|
| Rate for Payer: HFN Commercial |
$3,426.08
|
| Rate for Payer: Multiplan Commercial |
$2,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,234.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,426.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,824.76
|
| Rate for Payer: Quartz Commercial |
$2,234.40
|
| Rate for Payer: WEA Trust Commercial |
$2,048.20
|
| Rate for Payer: WPS Commercial |
$2,758.37
|
|
|
SCOPE SANI DISPOSABLE ANOSCOPE 82420
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2963326
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
SCOPE SANI DISPOSABLE ANOSCOPE 82420
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2963326
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Aetna Managed Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.24
|
| 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: Dean Health DHI/DHP/ASO |
$21.26
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.50
|
| 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 |
$24.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
SCORING TEMPLATES
|
Facility
|
IP
|
$1,592.00
|
|
| Hospital Charge Code |
2972352
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$780.08 |
| Max. Negotiated Rate |
$1,464.64 |
| Rate for Payer: Aetna Commercial |
$1,432.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,369.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.76
|
| Rate for Payer: Cash Price |
$477.60
|
| Rate for Payer: Cigna Commercial |
$1,464.64
|
| Rate for Payer: Health EOS Commercial |
$1,416.88
|
| Rate for Payer: HFN Commercial |
$1,464.64
|
| Rate for Payer: Multiplan Commercial |
$1,273.60
|
| Rate for Payer: NAPHCARE Commercial |
$955.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,464.64
|
| Rate for Payer: Quartz Beloit One Network |
$780.08
|
| Rate for Payer: Quartz Commercial |
$955.20
|
| Rate for Payer: WEA Trust Commercial |
$875.60
|
| Rate for Payer: WPS Commercial |
$1,179.19
|
|
|
SCORING TEMPLATES
|
Facility
|
OP
|
$1,592.00
|
|
| Hospital Charge Code |
2972352
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$445.76 |
| Max. Negotiated Rate |
$6,368.00 |
| Rate for Payer: Aetna Commercial |
$1,432.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,369.12
|
| Rate for Payer: Aetna Managed Medicare |
$445.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,034.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$796.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$764.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$843.76
|
| Rate for Payer: Cash Price |
$477.60
|
| Rate for Payer: Cigna Commercial |
$1,464.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$890.88
|
| Rate for Payer: Health EOS Commercial |
$1,416.88
|
| Rate for Payer: HFN Commercial |
$1,464.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,194.00
|
| Rate for Payer: Multiplan Commercial |
$1,273.60
|
| Rate for Payer: NAPHCARE Commercial |
$955.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,464.64
|
| Rate for Payer: Quartz Beloit One Network |
$780.08
|
| Rate for Payer: Quartz Commercial |
$1,034.80
|
| Rate for Payer: Quartz Medicare Advantage |
$955.20
|
| Rate for Payer: The Alliance Commercial |
$6,368.00
|
| Rate for Payer: WEA Trust Commercial |
$875.60
|
| Rate for Payer: WPS Commercial |
$1,179.19
|
|
|
Screen - Pulmonary Function Test Charge
|
Facility
|
OP
|
$434.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
3006992
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$154.39 |
| Max. Negotiated Rate |
$617.56 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.32
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$242.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$282.10
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: The Alliance Commercial |
$617.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$325.50
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
