|
Aural Rehab Next 15 Min
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 92627
|
| Hospital Charge Code |
3203483
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$14.46 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$14.46
|
| Rate for Payer: Anthem Medicare Advantage |
$14.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.46
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.46
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.46
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$21.68
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$14.46
|
| Rate for Payer: The Alliance Commercial |
$36.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.46
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$57.82
|
|
|
Aural Rehab Next 15 Min
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 92627
|
| Hospital Charge Code |
3203483
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$34.94
|
| 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 |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$74.88
|
| Rate for Payer: The Alliance Commercial |
$57.82
|
| Rate for Payer: United Healthcare PPO |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
.Auto Diff
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Aetna Managed Medicare |
$8.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.41
|
| Rate for Payer: Anthem Medicare Advantage |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.08
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.08
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.08
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: NAPHCARE Commercial |
$12.12
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$141.28
|
| Rate for Payer: Quartz Medicare Advantage |
$8.08
|
| Rate for Payer: The Alliance Commercial |
$32.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.08
|
| Rate for Payer: United Healthcare PPO |
$163.02
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: Wellcare Medicare |
$8.08
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
.Auto Diff
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$206.49 |
| Rate for Payer: Aetna Commercial |
$206.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Aetna Managed Medicare |
$8.08
|
| Rate for Payer: Anthem Medicare Advantage |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.08
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$206.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.08
|
| Rate for Payer: Health EOS Commercial |
$197.80
|
| Rate for Payer: HFN Commercial |
$206.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.08
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: NAPHCARE Commercial |
$12.12
|
| Rate for Payer: Preferred Network Access Commercial |
$206.49
|
| Rate for Payer: Quartz Beloit One Network |
$95.64
|
| Rate for Payer: Quartz Commercial |
$123.90
|
| Rate for Payer: Quartz Medicare Advantage |
$8.08
|
| Rate for Payer: The Alliance Commercial |
$31.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.08
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$35.56
|
|
|
.Auto Diff
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.51 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$40,071.18
|
|
|
Service Code
|
APR-DRG 0082
|
| Min. Negotiated Rate |
$35,593.72 |
| Max. Negotiated Rate |
$40,071.18 |
| Rate for Payer: Anthem Medicaid |
$38,370.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$38,370.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38,370.36
|
| Rate for Payer: Dean Health Medicaid |
$38,370.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$35,593.72
|
| Rate for Payer: Managed Health Services Medicaid |
$40,071.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$38,370.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$38,370.36
|
| Rate for Payer: United Healthcare Medicaid |
$38,370.36
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$33,845.68
|
|
|
Service Code
|
APR-DRG 0081
|
| Min. Negotiated Rate |
$30,063.84 |
| Max. Negotiated Rate |
$33,845.68 |
| Rate for Payer: Anthem Medicaid |
$32,409.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$32,409.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32,409.10
|
| Rate for Payer: Dean Health Medicaid |
$32,409.10
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30,063.84
|
| Rate for Payer: Managed Health Services Medicaid |
$33,845.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,409.10
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32,409.10
|
| Rate for Payer: United Healthcare Medicaid |
$32,409.10
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$51,119.25
|
|
|
Service Code
|
APR-DRG 0083
|
| Min. Negotiated Rate |
$45,407.30 |
| Max. Negotiated Rate |
$51,119.25 |
| Rate for Payer: Anthem Medicaid |
$48,949.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$48,949.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48,949.50
|
| Rate for Payer: Dean Health Medicaid |
$48,949.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$45,407.30
|
| Rate for Payer: Managed Health Services Medicaid |
$51,119.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$48,949.50
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$48,949.50
|
| Rate for Payer: United Healthcare Medicaid |
$48,949.50
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$72,601.61
|
|
|
Service Code
|
APR-DRG 0084
|
| Min. Negotiated Rate |
$64,489.28 |
| Max. Negotiated Rate |
$72,601.61 |
| Rate for Payer: Anthem Medicaid |
$69,520.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$69,520.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69,520.04
|
| Rate for Payer: Dean Health Medicaid |
$69,520.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$64,489.28
|
| Rate for Payer: Managed Health Services Medicaid |
$72,601.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$69,520.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$69,520.04
|
| Rate for Payer: United Healthcare Medicaid |
$69,520.04
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$171,123.68
|
|
|
Service Code
|
MSDRG 016
|
| Min. Negotiated Rate |
$45,917.59 |
| Max. Negotiated Rate |
$171,123.68 |
| Rate for Payer: Aetna Managed Medicare |
$45,917.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129,381.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99,169.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94,217.71
|
| Rate for Payer: Anthem Medicare Advantage |
$45,917.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45,917.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45,917.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$45,917.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104,590.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$45,917.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45,917.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45,917.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$45,917.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$45,917.59
|
| Rate for Payer: NAPHCARE Commercial |
$68,876.39
|
| Rate for Payer: Quartz Medicare Advantage |
$45,917.59
|
| Rate for Payer: The Alliance Commercial |
$171,123.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45,917.59
|
| Rate for Payer: Wellcare Medicare |
$45,917.59
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$171,123.68
|
|
|
Service Code
|
MSDRG 017
|
| Min. Negotiated Rate |
$42,108.39 |
| Max. Negotiated Rate |
$171,123.68 |
| Rate for Payer: Aetna Managed Medicare |
$42,108.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105,567.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80,916.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76,876.33
|
| Rate for Payer: Anthem Medicare Advantage |
$42,108.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$42,108.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$42,108.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$42,108.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85,339.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$42,108.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42,108.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$42,108.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$42,108.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$42,108.39
|
| Rate for Payer: NAPHCARE Commercial |
$63,162.59
|
| Rate for Payer: Quartz Medicare Advantage |
$42,108.39
|
| Rate for Payer: The Alliance Commercial |
$171,123.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$42,108.39
|
| Rate for Payer: Wellcare Medicare |
$42,108.39
|
|
|
AUTOLOGOUS CARTILAGE IMPLANTATION PROCEDURE (MACI)
|
Facility
|
IP
|
$62,498.00
|
|
|
Service Code
|
CPT 27412
|
| Hospital Charge Code |
5416772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31,848.98 |
| Max. Negotiated Rate |
$59,798.09 |
| Rate for Payer: Aetna Commercial |
$58,498.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55,898.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34,448.90
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cigna Commercial |
$59,798.09
|
| Rate for Payer: Health EOS Commercial |
$57,848.15
|
| Rate for Payer: HFN Commercial |
$59,798.09
|
| Rate for Payer: Multiplan Commercial |
$51,998.34
|
| Rate for Payer: Preferred Network Access Commercial |
$59,798.09
|
| Rate for Payer: Quartz Beloit One Network |
$31,848.98
|
| Rate for Payer: Quartz Commercial |
$38,998.75
|
| Rate for Payer: WEA Trust Commercial |
$35,748.86
|
| Rate for Payer: WPS Commercial |
$48,142.21
|
|
|
AUTOLOGOUS CARTILAGE IMPLANTATION PROCEDURE (MACI)
|
Facility
|
OP
|
$62,498.00
|
|
|
Service Code
|
CPT 27412
|
| Hospital Charge Code |
5416772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,807.99 |
| Max. Negotiated Rate |
$59,798.09 |
| Rate for Payer: Aetna Commercial |
$58,498.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55,898.21
|
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34,448.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cigna Commercial |
$59,798.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Health EOS Commercial |
$57,848.15
|
| Rate for Payer: HFN Commercial |
$59,798.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: Multiplan Commercial |
$51,998.34
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Preferred Network Access Commercial |
$59,798.09
|
| Rate for Payer: Quartz Beloit One Network |
$31,848.98
|
| Rate for Payer: Quartz Commercial |
$42,248.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: WEA Trust Commercial |
$35,748.86
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
| Rate for Payer: WPS Commercial |
$48,142.21
|
|
|
AUTOSCORE TEST FORM
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
2971762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
AUTOSCORE TEST FORM
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
2971762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Avastin 10 mg Charge
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.84 |
| Max. Negotiated Rate |
$283.21 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.16
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$184.70
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$228.01
|
|
|
Avastin 10 mg Charge
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.58 |
| Max. Negotiated Rate |
$292.45 |
| Rate for Payer: Aetna Commercial |
$292.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Aetna Managed Medicare |
$76.58
|
| Rate for Payer: Anthem Medicare Advantage |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.58
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$292.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.12
|
| Rate for Payer: Health EOS Commercial |
$280.13
|
| Rate for Payer: HFN Commercial |
$292.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.58
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: NAPHCARE Commercial |
$114.86
|
| Rate for Payer: Preferred Network Access Commercial |
$292.45
|
| Rate for Payer: Quartz Beloit One Network |
$135.45
|
| Rate for Payer: Quartz Commercial |
$175.47
|
| Rate for Payer: Quartz Medicare Advantage |
$76.58
|
| Rate for Payer: The Alliance Commercial |
$210.58
|
| Rate for Payer: United Healthcare Medicaid |
$76.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.58
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$192.81
|
|
|
Avastin 10 mg Charge
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.58 |
| Max. Negotiated Rate |
$306.30 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Aetna Managed Medicare |
$76.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$153.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$147.76
|
| Rate for Payer: Anthem Medicare Advantage |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.58
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$76.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$76.58
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$76.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$76.58
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: NAPHCARE Commercial |
$114.86
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$200.10
|
| Rate for Payer: Quartz Medicare Advantage |
$76.58
|
| Rate for Payer: The Alliance Commercial |
$306.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.58
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: Wellcare Medicare |
$76.58
|
| Rate for Payer: WPS Commercial |
$192.81
|
|
|
Avastin 1.25 mg Charge
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$72.12 |
| Rate for Payer: Aetna Commercial |
$72.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$72.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.55
|
| Rate for Payer: Health EOS Commercial |
$69.09
|
| Rate for Payer: HFN Commercial |
$72.12
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: Preferred Network Access Commercial |
$72.12
|
| Rate for Payer: Quartz Beloit One Network |
$33.40
|
| Rate for Payer: Quartz Commercial |
$43.27
|
| Rate for Payer: The Alliance Commercial |
$37.96
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
Avastin 1.25 mg Charge
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Aetna Managed Medicare |
$1.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.44
|
| Rate for Payer: Anthem Medicare Advantage |
$1.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.91
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: NAPHCARE Commercial |
$2.87
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$49.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.91
|
| Rate for Payer: The Alliance Commercial |
$7.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.91
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: Wellcare Medicare |
$1.91
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
Avastin 1.25 mg Charge
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$45.55
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
Avastin .25 mg J9035
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$210.58 |
| Rate for Payer: Aetna Commercial |
$72.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Aetna Managed Medicare |
$76.58
|
| Rate for Payer: Anthem Medicare Advantage |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.58
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$72.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.12
|
| Rate for Payer: Health EOS Commercial |
$69.09
|
| Rate for Payer: HFN Commercial |
$72.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.58
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: NAPHCARE Commercial |
$114.86
|
| Rate for Payer: Preferred Network Access Commercial |
$72.12
|
| Rate for Payer: Quartz Beloit One Network |
$33.40
|
| Rate for Payer: Quartz Commercial |
$43.27
|
| Rate for Payer: Quartz Medicare Advantage |
$76.58
|
| Rate for Payer: The Alliance Commercial |
$210.58
|
| Rate for Payer: United Healthcare Medicaid |
$76.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.58
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$192.81
|
|
|
Avastin .25 mg J9035
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$45.55
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
Avastin .25 mg J9035
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
6195203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.44 |
| Max. Negotiated Rate |
$306.30 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Aetna Managed Medicare |
$76.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.44
|
| Rate for Payer: Anthem Medicare Advantage |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.58
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$76.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$76.58
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$284.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$76.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$76.58
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: NAPHCARE Commercial |
$114.86
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$49.35
|
| Rate for Payer: Quartz Medicare Advantage |
$76.58
|
| Rate for Payer: The Alliance Commercial |
$306.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.58
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: Wellcare Medicare |
$76.58
|
| Rate for Payer: WPS Commercial |
$192.81
|
|
|
Aviator 4mm x 2cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2546812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
