|
TD Vaccine No Prsrv >/= 7 IM 90714
|
Facility
IP
|
$106.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3455569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$78.51
|
|
|
TD Vaccine No Prsrv >/= 7 IM 90714
|
Facility
OP
|
$106.00
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
3455569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$97.52 |
| Rate for Payer: Aetna Commercial |
$95.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.16
|
| Rate for Payer: Aetna Managed Medicare |
$29.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.18
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$97.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.91
|
| Rate for Payer: Health EOS Commercial |
$94.34
|
| Rate for Payer: HFN Commercial |
$97.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$84.80
|
| Rate for Payer: NAPHCARE Commercial |
$63.60
|
| Rate for Payer: Preferred Network Access Commercial |
$97.52
|
| Rate for Payer: Quartz Beloit One Network |
$51.94
|
| Rate for Payer: Quartz Commercial |
$68.90
|
| Rate for Payer: Quartz Medicare Advantage |
$63.60
|
| Rate for Payer: WEA Trust Commercial |
$58.30
|
| Rate for Payer: WPS Commercial |
$47.07
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTION, BABY (1-6)
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960406
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, FULL MOUTH
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960408
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
TEETH EXTRACTIONS, MULTIPLE (1-6)
|
Facility
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960409
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
TEETH EXTRACTION, WISDOM TEETH
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH EXTRACTION, WISDOM TEETH
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH FILLINGS
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960407
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
TEETH FILLINGS
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960407
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Facility
IP
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$128.38 |
| Max. Negotiated Rate |
$241.04 |
| Rate for Payer: Aetna Commercial |
$235.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.86
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$241.04
|
| Rate for Payer: Health EOS Commercial |
$233.18
|
| Rate for Payer: HFN Commercial |
$241.04
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: NAPHCARE Commercial |
$157.20
|
| Rate for Payer: Preferred Network Access Commercial |
$241.04
|
| Rate for Payer: Quartz Beloit One Network |
$128.38
|
| Rate for Payer: Quartz Commercial |
$157.20
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: WPS Commercial |
$194.06
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Professional
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$248.90 |
| Rate for Payer: Aetna Commercial |
$248.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.32
|
| Rate for Payer: Aetna Managed Medicare |
$11.98
|
| Rate for Payer: Anthem Medicare Advantage |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.98
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$248.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$131.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.98
|
| Rate for Payer: Health EOS Commercial |
$238.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.98
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: Preferred Network Access Commercial |
$248.90
|
| Rate for Payer: Quartz Beloit One Network |
$115.28
|
| Rate for Payer: Quartz Commercial |
$149.34
|
| Rate for Payer: Quartz Medicare Advantage |
$11.98
|
| Rate for Payer: The Alliance Commercial |
$47.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: WPS Commercial |
$52.71
|
|
|
Teichoic Acid Antibody w/ Reflex
|
Facility
OP
|
$262.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
983419
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$1,048.00 |
| Rate for Payer: Aetna Commercial |
$235.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.32
|
| Rate for Payer: Aetna Managed Medicare |
$11.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.89
|
| Rate for Payer: Anthem Medicaid |
$12.38
|
| Rate for Payer: Anthem Medicare Advantage |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.98
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$241.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.38
|
| Rate for Payer: Dean Health Medicaid |
$12.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.98
|
| Rate for Payer: Health EOS Commercial |
$233.18
|
| Rate for Payer: HFN Commercial |
$241.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.98
|
| Rate for Payer: Managed Health Services Medicaid |
$12.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.98
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: NAPHCARE Commercial |
$17.97
|
| Rate for Payer: Preferred Network Access Commercial |
$241.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.38
|
| Rate for Payer: Quartz Beloit One Network |
$128.38
|
| Rate for Payer: Quartz Commercial |
$170.30
|
| Rate for Payer: Quartz Medicare Advantage |
$11.98
|
| Rate for Payer: The Alliance Commercial |
$1,048.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.98
|
| Rate for Payer: United Healthcare PPO |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: Wellcare Medicare |
$11.98
|
| Rate for Payer: WMAP Medicaid |
$12.38
|
| Rate for Payer: WPS Commercial |
$194.06
|
|
|
Telemetry (All units EXCEPT Intermediate) - Devices and Equipment
|
Facility
OP
|
$591.00
|
|
| Hospital Charge Code |
3716170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$165.48 |
| Max. Negotiated Rate |
$2,364.00 |
| Rate for Payer: Aetna Commercial |
$531.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.26
|
| Rate for Payer: Aetna Managed Medicare |
$165.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$384.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$283.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.23
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$543.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.72
|
| Rate for Payer: Health EOS Commercial |
$525.99
|
| Rate for Payer: HFN Commercial |
$543.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$443.25
|
| Rate for Payer: Multiplan Commercial |
$472.80
|
| Rate for Payer: NAPHCARE Commercial |
$354.60
|
| Rate for Payer: Preferred Network Access Commercial |
$543.72
|
| Rate for Payer: Quartz Beloit One Network |
$289.59
|
| Rate for Payer: Quartz Commercial |
$384.15
|
| Rate for Payer: Quartz Medicare Advantage |
$354.60
|
| Rate for Payer: The Alliance Commercial |
$2,364.00
|
| Rate for Payer: WEA Trust Commercial |
$325.05
|
| Rate for Payer: WPS Commercial |
$437.75
|
|
|
Telemetry (All units EXCEPT Intermediate) - Devices and Equipment
|
Facility
IP
|
$591.00
|
|
| Hospital Charge Code |
3716170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$289.59 |
| Max. Negotiated Rate |
$543.72 |
| Rate for Payer: Aetna Commercial |
$531.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.23
|
| Rate for Payer: Cash Price |
$177.30
|
| Rate for Payer: Cigna Commercial |
$543.72
|
| Rate for Payer: Health EOS Commercial |
$525.99
|
| Rate for Payer: HFN Commercial |
$543.72
|
| Rate for Payer: Multiplan Commercial |
$472.80
|
| Rate for Payer: NAPHCARE Commercial |
$354.60
|
| Rate for Payer: Preferred Network Access Commercial |
$543.72
|
| Rate for Payer: Quartz Beloit One Network |
$289.59
|
| Rate for Payer: Quartz Commercial |
$354.60
|
| Rate for Payer: WEA Trust Commercial |
$325.05
|
| Rate for Payer: WPS Commercial |
$437.75
|
|
|
TELESCOPIC MOTOR STRUT LONG 239-351MM 4934-0-360
|
Facility
IP
|
$10,071.06
|
|
| Hospital Charge Code |
6240151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,934.82 |
| Max. Negotiated Rate |
$9,265.38 |
| Rate for Payer: Aetna Commercial |
$9,063.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,337.66
|
| Rate for Payer: Cash Price |
$3,021.32
|
| Rate for Payer: Cigna Commercial |
$9,265.38
|
| Rate for Payer: Health EOS Commercial |
$8,963.24
|
| Rate for Payer: HFN Commercial |
$9,265.38
|
| Rate for Payer: Multiplan Commercial |
$8,056.85
|
| Rate for Payer: NAPHCARE Commercial |
$6,042.64
|
| Rate for Payer: Preferred Network Access Commercial |
$9,265.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,934.82
|
| Rate for Payer: Quartz Commercial |
$6,042.64
|
| Rate for Payer: WEA Trust Commercial |
$5,539.08
|
| Rate for Payer: WPS Commercial |
$7,459.63
|
|
|
TELESCOPIC MOTOR STRUT LONG 239-351MM 4934-0-360
|
Facility
OP
|
$10,071.06
|
|
| Hospital Charge Code |
6240151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,819.90 |
| Max. Negotiated Rate |
$40,284.24 |
| Rate for Payer: Aetna Commercial |
$9,063.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,661.11
|
| Rate for Payer: Aetna Managed Medicare |
$2,819.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,546.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,035.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,834.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,337.66
|
| Rate for Payer: Cash Price |
$3,021.32
|
| Rate for Payer: Cigna Commercial |
$9,265.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,635.77
|
| Rate for Payer: Health EOS Commercial |
$8,963.24
|
| Rate for Payer: HFN Commercial |
$9,265.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,553.30
|
| Rate for Payer: Multiplan Commercial |
$8,056.85
|
| Rate for Payer: NAPHCARE Commercial |
$6,042.64
|
| Rate for Payer: Preferred Network Access Commercial |
$9,265.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,934.82
|
| Rate for Payer: Quartz Commercial |
$6,546.19
|
| Rate for Payer: Quartz Medicare Advantage |
$6,042.64
|
| Rate for Payer: The Alliance Commercial |
$40,284.24
|
| Rate for Payer: WEA Trust Commercial |
$5,539.08
|
| Rate for Payer: WPS Commercial |
$7,459.63
|
|
|
TELESCOPIC MOTOR STRUT MEDIUM 187-247MM 4934-0-270
|
Facility
OP
|
$10,071.76
|
|
| Hospital Charge Code |
6240150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,820.09 |
| Max. Negotiated Rate |
$40,287.04 |
| Rate for Payer: Aetna Commercial |
$9,064.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,661.71
|
| Rate for Payer: Aetna Managed Medicare |
$2,820.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,546.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,035.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,834.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,338.03
|
| Rate for Payer: Cash Price |
$3,021.53
|
| Rate for Payer: Cigna Commercial |
$9,266.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,636.16
|
| Rate for Payer: Health EOS Commercial |
$8,963.87
|
| Rate for Payer: HFN Commercial |
$9,266.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,553.82
|
| Rate for Payer: Multiplan Commercial |
$8,057.41
|
| Rate for Payer: NAPHCARE Commercial |
$6,043.06
|
| Rate for Payer: Preferred Network Access Commercial |
$9,266.02
|
| Rate for Payer: Quartz Beloit One Network |
$4,935.16
|
| Rate for Payer: Quartz Commercial |
$6,546.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,043.06
|
| Rate for Payer: The Alliance Commercial |
$40,287.04
|
| Rate for Payer: WEA Trust Commercial |
$5,539.47
|
| Rate for Payer: WPS Commercial |
$7,460.15
|
|
|
TELESCOPIC MOTOR STRUT MEDIUM 187-247MM 4934-0-270
|
Facility
IP
|
$10,071.76
|
|
| Hospital Charge Code |
6240150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,935.16 |
| Max. Negotiated Rate |
$9,266.02 |
| Rate for Payer: Aetna Commercial |
$9,064.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,338.03
|
| Rate for Payer: Cash Price |
$3,021.53
|
| Rate for Payer: Cigna Commercial |
$9,266.02
|
| Rate for Payer: Health EOS Commercial |
$8,963.87
|
| Rate for Payer: HFN Commercial |
$9,266.02
|
| Rate for Payer: Multiplan Commercial |
$8,057.41
|
| Rate for Payer: NAPHCARE Commercial |
$6,043.06
|
| Rate for Payer: Preferred Network Access Commercial |
$9,266.02
|
| Rate for Payer: Quartz Beloit One Network |
$4,935.16
|
| Rate for Payer: Quartz Commercial |
$6,043.06
|
| Rate for Payer: WEA Trust Commercial |
$5,539.47
|
| Rate for Payer: WPS Commercial |
$7,460.15
|
|
|
Teletherapy Isodose Plan-Complex 7730726
|
Professional
|
$2,185.00
|
|
|
Service Code
|
CPT 77307 26
|
| Hospital Charge Code |
5258631
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$148.16 |
| Max. Negotiated Rate |
$2,075.75 |
| Rate for Payer: Aetna Commercial |
$2,075.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,879.10
|
| Rate for Payer: Aetna Managed Medicare |
$148.16
|
| Rate for Payer: Anthem Medicare Advantage |
$148.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$148.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$148.16
|
| Rate for Payer: Cash Price |
$655.50
|
| Rate for Payer: Cash Price |
$655.50
|
| Rate for Payer: Cigna Commercial |
$2,075.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,092.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.16
|
| Rate for Payer: Health EOS Commercial |
$1,988.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$523.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$523.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$148.16
|
| Rate for Payer: Multiplan Commercial |
$1,748.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,075.75
|
| Rate for Payer: Quartz Beloit One Network |
$961.40
|
| Rate for Payer: Quartz Commercial |
$1,245.45
|
| Rate for Payer: Quartz Medicare Advantage |
$148.16
|
| Rate for Payer: The Alliance Commercial |
$563.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$148.16
|
| Rate for Payer: WEA Trust Commercial |
$1,201.75
|
| Rate for Payer: WPS Commercial |
$740.80
|
|
|
Teletherapy Isodose Plan-Simple 7730626
|
Professional
|
$861.00
|
|
|
Service Code
|
CPT 77306 26
|
| Hospital Charge Code |
5258630
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.58 |
| Max. Negotiated Rate |
$817.95 |
| Rate for Payer: Aetna Commercial |
$817.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$71.58
|
| Rate for Payer: Anthem Medicare Advantage |
$71.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$71.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$71.58
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$817.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$430.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.58
|
| Rate for Payer: Health EOS Commercial |
$783.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$71.58
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: Preferred Network Access Commercial |
$817.95
|
| Rate for Payer: Quartz Beloit One Network |
$378.84
|
| Rate for Payer: Quartz Commercial |
$490.77
|
| Rate for Payer: Quartz Medicare Advantage |
$71.58
|
| Rate for Payer: The Alliance Commercial |
$272.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$71.58
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$357.90
|
|
|
Temperature Probe Indwelling/Continuous* - Urinary catheter type:
|
Facility
OP
|
$664.00
|
|
| Hospital Charge Code |
5877765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$185.92 |
| Max. Negotiated Rate |
$2,656.00 |
| Rate for Payer: Aetna Commercial |
$597.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$571.04
|
| Rate for Payer: Aetna Managed Medicare |
$185.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$431.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$332.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$318.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$351.92
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$371.57
|
| Rate for Payer: Health EOS Commercial |
$590.96
|
| Rate for Payer: HFN Commercial |
$610.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$498.00
|
| Rate for Payer: Multiplan Commercial |
$531.20
|
| Rate for Payer: NAPHCARE Commercial |
$398.40
|
| Rate for Payer: Preferred Network Access Commercial |
$610.88
|
| Rate for Payer: Quartz Beloit One Network |
$325.36
|
| Rate for Payer: Quartz Commercial |
$431.60
|
| Rate for Payer: Quartz Medicare Advantage |
$398.40
|
| Rate for Payer: The Alliance Commercial |
$2,656.00
|
| Rate for Payer: WEA Trust Commercial |
$365.20
|
| Rate for Payer: WPS Commercial |
$491.82
|
|
|
Temperature Probe Indwelling/Continuous* - Urinary catheter type:
|
Facility
IP
|
$664.00
|
|
| Hospital Charge Code |
5877765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.36 |
| Max. Negotiated Rate |
$610.88 |
| Rate for Payer: Aetna Commercial |
$597.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$351.92
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: Health EOS Commercial |
$590.96
|
| Rate for Payer: HFN Commercial |
$610.88
|
| Rate for Payer: Multiplan Commercial |
$531.20
|
| Rate for Payer: NAPHCARE Commercial |
$398.40
|
| Rate for Payer: Preferred Network Access Commercial |
$610.88
|
| Rate for Payer: Quartz Beloit One Network |
$325.36
|
| Rate for Payer: Quartz Commercial |
$398.40
|
| Rate for Payer: WEA Trust Commercial |
$365.20
|
| Rate for Payer: WPS Commercial |
$491.82
|
|
