|
TPMT Enzyme Activity
|
Professional
|
$313.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2778840
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.17 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Aetna Commercial |
$297.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.18
|
| Rate for Payer: Aetna Managed Medicare |
$22.17
|
| Rate for Payer: Anthem Medicare Advantage |
$22.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.17
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$297.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.17
|
| Rate for Payer: Health EOS Commercial |
$284.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.17
|
| Rate for Payer: Multiplan Commercial |
$250.40
|
| Rate for Payer: Preferred Network Access Commercial |
$297.35
|
| Rate for Payer: Quartz Beloit One Network |
$137.72
|
| Rate for Payer: Quartz Commercial |
$178.41
|
| Rate for Payer: Quartz Medicare Advantage |
$22.17
|
| Rate for Payer: The Alliance Commercial |
$87.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.17
|
| Rate for Payer: WEA Trust Commercial |
$172.15
|
| Rate for Payer: WPS Commercial |
$97.55
|
|
|
TPMT Interp & Report
|
Facility
IP
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
TPMT Interp & Report
|
Facility
OP
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: United Healthcare PPO |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
TPMT Interp & Report
|
Professional
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: Aetna Commercial |
$41.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$41.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.40
|
| Rate for Payer: Health EOS Commercial |
$40.04
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: Preferred Network Access Commercial |
$41.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.08
|
| Rate for Payer: The Alliance Commercial |
$22.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
TPMT Lysis
|
Facility
IP
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TPMT Lysis
|
Professional
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.60
|
| Rate for Payer: Health EOS Commercial |
$55.51
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.95
|
| Rate for Payer: Quartz Beloit One Network |
$26.84
|
| Rate for Payer: Quartz Commercial |
$34.77
|
| Rate for Payer: The Alliance Commercial |
$30.50
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TPMT Lysis
|
Facility
OP
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$244.00 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: United Healthcare PPO |
$45.75
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TPMT Nucleic Acid Probe
|
Facility
OP
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: United Healthcare PPO |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
TPMT Nucleic Acid Probe
|
Facility
IP
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
TPMT Nucleic Acid Probe
|
Professional
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$41.80 |
| Rate for Payer: WPS Commercial |
$32.59
|
| Rate for Payer: Aetna Commercial |
$41.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$41.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.40
|
| Rate for Payer: Health EOS Commercial |
$40.04
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: Preferred Network Access Commercial |
$41.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.08
|
| Rate for Payer: The Alliance Commercial |
$22.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
|
|
TPMY Lysis
|
Facility
OP
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$244.00 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: United Healthcare PPO |
$45.75
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TPMY Lysis
|
Professional
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$57.95 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$57.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.60
|
| Rate for Payer: Health EOS Commercial |
$55.51
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.95
|
| Rate for Payer: Quartz Beloit One Network |
$26.84
|
| Rate for Payer: Quartz Commercial |
$34.77
|
| Rate for Payer: The Alliance Commercial |
$30.50
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TPMY Lysis
|
Facility
IP
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
TRABECULECTOMY
|
Facility
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
TRABECULECTOMY
|
Facility
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
Trabeculoplasty By Laser; 1 or more sessions
|
Professional
|
$1,298.00
|
|
|
Service Code
|
CPT 65855
|
| Hospital Charge Code |
1188907
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$194.57 |
| Max. Negotiated Rate |
$1,233.10 |
| Rate for Payer: Aetna Commercial |
$1,233.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,116.28
|
| Rate for Payer: Aetna Managed Medicare |
$194.57
|
| Rate for Payer: Anthem Medicare Advantage |
$194.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$194.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$194.57
|
| Rate for Payer: Cash Price |
$389.40
|
| Rate for Payer: Cash Price |
$389.40
|
| Rate for Payer: Cigna Commercial |
$1,233.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$649.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$194.57
|
| Rate for Payer: Health EOS Commercial |
$1,181.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$691.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$691.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$194.57
|
| Rate for Payer: Multiplan Commercial |
$1,038.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.10
|
| Rate for Payer: Quartz Beloit One Network |
$571.12
|
| Rate for Payer: Quartz Commercial |
$739.86
|
| Rate for Payer: Quartz Medicare Advantage |
$194.57
|
| Rate for Payer: The Alliance Commercial |
$826.92
|
| Rate for Payer: United Healthcare Medicaid |
$269.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$194.57
|
| Rate for Payer: WEA Trust Commercial |
$713.90
|
| Rate for Payer: WPS Commercial |
$875.56
|
|
|
Trabeculoplasty By Laser; 1 or more sessions 6585550
|
Professional
|
$2,594.00
|
|
|
Service Code
|
CPT 65855 50
|
| Hospital Charge Code |
5547178
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$269.02 |
| Max. Negotiated Rate |
$2,464.30 |
| Rate for Payer: Aetna Commercial |
$2,464.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,230.84
|
| Rate for Payer: Cash Price |
$778.20
|
| Rate for Payer: Cash Price |
$778.20
|
| Rate for Payer: Cigna Commercial |
$2,464.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,297.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,556.40
|
| Rate for Payer: Health EOS Commercial |
$2,360.54
|
| Rate for Payer: Multiplan Commercial |
$2,075.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,464.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,141.36
|
| Rate for Payer: Quartz Commercial |
$1,478.58
|
| Rate for Payer: The Alliance Commercial |
$1,297.00
|
| Rate for Payer: United Healthcare Medicaid |
$269.02
|
| Rate for Payer: WEA Trust Commercial |
$1,426.70
|
| Rate for Payer: WPS Commercial |
$1,921.38
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 6 SHILEY FLEX TRACH TUBE G57716
|
Facility
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5617788
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,792.91 |
| Max. Negotiated Rate |
$3,366.28 |
| Rate for Payer: Aetna Commercial |
$3,293.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.27
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,366.28
|
| Rate for Payer: Health EOS Commercial |
$3,256.51
|
| Rate for Payer: HFN Commercial |
$3,366.28
|
| Rate for Payer: Multiplan Commercial |
$2,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,195.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,366.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,792.91
|
| Rate for Payer: Quartz Commercial |
$2,195.40
|
| Rate for Payer: WEA Trust Commercial |
$2,012.45
|
| Rate for Payer: WPS Commercial |
$2,710.22
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 6 SHILEY FLEX TRACH TUBE G57716
|
Facility
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5617788
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,024.52 |
| Max. Negotiated Rate |
$14,636.00 |
| Rate for Payer: Aetna Commercial |
$3,293.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,146.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,024.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,378.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,829.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,756.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.27
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,366.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,047.58
|
| Rate for Payer: Health EOS Commercial |
$3,256.51
|
| Rate for Payer: HFN Commercial |
$3,366.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,744.25
|
| Rate for Payer: Multiplan Commercial |
$2,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,195.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,366.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,792.91
|
| Rate for Payer: Quartz Commercial |
$2,378.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,195.40
|
| Rate for Payer: The Alliance Commercial |
$14,636.00
|
| Rate for Payer: WEA Trust Commercial |
$2,012.45
|
| Rate for Payer: WPS Commercial |
$2,710.22
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 8 SHILEY FLEX TRACH TUBE G57717
|
Facility
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5617789
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,792.91 |
| Max. Negotiated Rate |
$3,366.28 |
| Rate for Payer: Aetna Commercial |
$3,293.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.27
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,366.28
|
| Rate for Payer: Health EOS Commercial |
$3,256.51
|
| Rate for Payer: HFN Commercial |
$3,366.28
|
| Rate for Payer: Multiplan Commercial |
$2,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,195.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,366.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,792.91
|
| Rate for Payer: Quartz Commercial |
$2,195.40
|
| Rate for Payer: WEA Trust Commercial |
$2,012.45
|
| Rate for Payer: WPS Commercial |
$2,710.22
|
|
|
TRACH BLUE RHINO G2 W/JACKSON SZ 8 SHILEY FLEX TRACH TUBE G57717
|
Facility
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5617789
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,024.52 |
| Max. Negotiated Rate |
$14,636.00 |
| Rate for Payer: Aetna Commercial |
$3,293.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,146.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,024.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,378.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,829.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,756.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.27
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,366.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,047.58
|
| Rate for Payer: Health EOS Commercial |
$3,256.51
|
| Rate for Payer: HFN Commercial |
$3,366.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,744.25
|
| Rate for Payer: Multiplan Commercial |
$2,927.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,195.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,366.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,792.91
|
| Rate for Payer: Quartz Commercial |
$2,378.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,195.40
|
| Rate for Payer: The Alliance Commercial |
$14,636.00
|
| Rate for Payer: WEA Trust Commercial |
$2,012.45
|
| Rate for Payer: WPS Commercial |
$2,710.22
|
|
|
TRACH CUFF FLEX SHILEY 8CN85H
|
Facility
OP
|
$2,086.00
|
|
| Hospital Charge Code |
5415936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$8,344.00 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.96
|
| Rate for Payer: Aetna Managed Medicare |
$584.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,355.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,001.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,167.33
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,564.50
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,355.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,251.60
|
| Rate for Payer: The Alliance Commercial |
$8,344.00
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
|
TRACH CUFF FLEX SHILEY 8CN85H
|
Facility
IP
|
$2,086.00
|
|
| Hospital Charge Code |
5415936
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,022.14 |
| Max. Negotiated Rate |
$1,919.12 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,251.60
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
|
TRACHEAL TUBE 8.0MM UNCUFFED 504080
|
Facility
OP
|
$514.00
|
|
| Hospital Charge Code |
2963739
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$143.92 |
| Max. Negotiated Rate |
$2,056.00 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.04
|
| Rate for Payer: Aetna Managed Medicare |
$143.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.63
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$385.50
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$334.10
|
| Rate for Payer: Quartz Medicare Advantage |
$308.40
|
| Rate for Payer: The Alliance Commercial |
$2,056.00
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
|
TRACHEAL TUBE 8.0MM UNCUFFED 504080
|
Facility
IP
|
$514.00
|
|
| Hospital Charge Code |
2963739
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.86 |
| Max. Negotiated Rate |
$472.88 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$308.40
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
