|
TENSION FREE VAGINAL TAPE PROCEDURE
|
Facility
|
OP
|
$4,721.00
|
|
| Hospital Charge Code |
2960460
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,321.88 |
| Max. Negotiated Rate |
$18,884.00 |
| Rate for Payer: Aetna Commercial |
$4,248.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,060.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,321.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,068.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,360.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,266.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,502.13
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,343.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,641.87
|
| Rate for Payer: Health EOS Commercial |
$4,201.69
|
| Rate for Payer: HFN Commercial |
$4,343.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,540.75
|
| Rate for Payer: Multiplan Commercial |
$3,776.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,832.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,343.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,313.29
|
| Rate for Payer: Quartz Commercial |
$3,068.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,832.60
|
| Rate for Payer: The Alliance Commercial |
$18,884.00
|
| Rate for Payer: WEA Trust Commercial |
$2,596.55
|
| Rate for Payer: WPS Commercial |
$3,496.84
|
|
|
TENSOGRIP SIZE F #A938-11
|
Facility
|
OP
|
$891.00
|
|
| Hospital Charge Code |
2974062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$249.48 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.26
|
| Rate for Payer: Aetna Managed Medicare |
$249.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$579.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$445.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$427.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$498.60
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$668.25
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$579.15
|
| Rate for Payer: Quartz Medicare Advantage |
$534.60
|
| Rate for Payer: The Alliance Commercial |
$3,564.00
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
TENSOGRIP SIZE F #A938-11
|
Facility
|
IP
|
$891.00
|
|
| Hospital Charge Code |
2974062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$436.59 |
| Max. Negotiated Rate |
$819.72 |
| Rate for Payer: Aetna Commercial |
$801.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$766.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$472.23
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$819.72
|
| Rate for Payer: Health EOS Commercial |
$792.99
|
| Rate for Payer: HFN Commercial |
$819.72
|
| Rate for Payer: Multiplan Commercial |
$712.80
|
| Rate for Payer: NAPHCARE Commercial |
$534.60
|
| Rate for Payer: Preferred Network Access Commercial |
$819.72
|
| Rate for Payer: Quartz Beloit One Network |
$436.59
|
| Rate for Payer: Quartz Commercial |
$534.60
|
| Rate for Payer: WEA Trust Commercial |
$490.05
|
| Rate for Payer: WPS Commercial |
$659.96
|
|
|
TEST CABLE INTERSTIM 357501
|
Facility
|
OP
|
$854.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5384755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$239.12 |
| Max. Negotiated Rate |
$3,416.00 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Aetna Managed Medicare |
$239.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$409.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.90
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$640.50
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$555.10
|
| Rate for Payer: Quartz Medicare Advantage |
$512.40
|
| Rate for Payer: The Alliance Commercial |
$3,416.00
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
TEST CABLE INTERSTIM 357501
|
Facility
|
IP
|
$854.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5384755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$418.46 |
| Max. Negotiated Rate |
$785.68 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$512.40
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$56,760.00
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$20,417.18 |
| Max. Negotiated Rate |
$56,760.00 |
| Rate for Payer: Aetna Managed Medicare |
$20,417.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,477.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,091.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,389.36
|
| Rate for Payer: Anthem Medicare Advantage |
$20,417.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20,417.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20,417.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20,417.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35,955.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20,417.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41,396.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20,417.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20,417.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20,417.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20,417.18
|
| Rate for Payer: NAPHCARE Commercial |
$30,625.77
|
| Rate for Payer: Quartz Medicare Advantage |
$20,417.18
|
| Rate for Payer: The Alliance Commercial |
$56,760.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20,417.18
|
| Rate for Payer: United Healthcare PPO |
$32,227.74
|
| Rate for Payer: Wellcare Medicare |
$20,417.18
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$31,915.00
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$11,480.28 |
| Max. Negotiated Rate |
$31,915.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,480.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,966.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,136.39
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,180.82
|
| Rate for Payer: Anthem Medicare Advantage |
$11,480.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,480.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,480.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,480.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,182.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,480.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,173.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,480.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,480.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,480.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,480.28
|
| Rate for Payer: NAPHCARE Commercial |
$17,220.42
|
| Rate for Payer: Quartz Medicare Advantage |
$11,480.28
|
| Rate for Payer: The Alliance Commercial |
$31,915.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,480.28
|
| Rate for Payer: United Healthcare PPO |
$18,041.10
|
| Rate for Payer: Wellcare Medicare |
$11,480.28
|
|
|
TESTICLE, TORSION OF
|
Facility
|
IP
|
$1,048.00
|
|
| Hospital Charge Code |
2960439
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$513.52 |
| Max. Negotiated Rate |
$964.16 |
| Rate for Payer: Aetna Commercial |
$943.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$901.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.44
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$964.16
|
| Rate for Payer: Health EOS Commercial |
$932.72
|
| Rate for Payer: HFN Commercial |
$964.16
|
| Rate for Payer: Multiplan Commercial |
$838.40
|
| Rate for Payer: NAPHCARE Commercial |
$628.80
|
| Rate for Payer: Preferred Network Access Commercial |
$964.16
|
| Rate for Payer: Quartz Beloit One Network |
$513.52
|
| Rate for Payer: Quartz Commercial |
$628.80
|
| Rate for Payer: WEA Trust Commercial |
$576.40
|
| Rate for Payer: WPS Commercial |
$776.25
|
|
|
TESTICLE, TORSION OF
|
Facility
|
OP
|
$1,048.00
|
|
| Hospital Charge Code |
2960439
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$293.44 |
| Max. Negotiated Rate |
$4,192.00 |
| Rate for Payer: Aetna Commercial |
$943.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$901.28
|
| Rate for Payer: Aetna Managed Medicare |
$293.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$681.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$524.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$503.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$555.44
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$964.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$586.46
|
| Rate for Payer: Health EOS Commercial |
$932.72
|
| Rate for Payer: HFN Commercial |
$964.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$786.00
|
| Rate for Payer: Multiplan Commercial |
$838.40
|
| Rate for Payer: NAPHCARE Commercial |
$628.80
|
| Rate for Payer: Preferred Network Access Commercial |
$964.16
|
| Rate for Payer: Quartz Beloit One Network |
$513.52
|
| Rate for Payer: Quartz Commercial |
$681.20
|
| Rate for Payer: Quartz Medicare Advantage |
$628.80
|
| Rate for Payer: The Alliance Commercial |
$4,192.00
|
| Rate for Payer: WEA Trust Commercial |
$576.40
|
| Rate for Payer: WPS Commercial |
$776.25
|
|
|
TESTICULAR PROSTHESIS INSERTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960326
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| 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
|
|
|
TESTICULAR PROSTHESIS INSERTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960326
|
|
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
|
|
|
TEST KIT INTERSTIM 309201
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349488
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$409.36 |
| Max. Negotiated Rate |
$5,848.00 |
| Rate for Payer: Aetna Commercial |
$1,315.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,257.32
|
| Rate for Payer: Aetna Managed Medicare |
$409.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$950.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$731.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$701.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$774.86
|
| Rate for Payer: Cash Price |
$438.60
|
| Rate for Payer: Cigna Commercial |
$1,345.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$818.14
|
| Rate for Payer: Health EOS Commercial |
$1,301.18
|
| Rate for Payer: HFN Commercial |
$1,345.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,096.50
|
| Rate for Payer: Multiplan Commercial |
$1,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$877.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,345.04
|
| Rate for Payer: Quartz Beloit One Network |
$716.38
|
| Rate for Payer: Quartz Commercial |
$950.30
|
| Rate for Payer: Quartz Medicare Advantage |
$877.20
|
| Rate for Payer: The Alliance Commercial |
$5,848.00
|
| Rate for Payer: WEA Trust Commercial |
$804.10
|
| Rate for Payer: WPS Commercial |
$1,082.90
|
|
|
TEST KIT INTERSTIM 309201
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349488
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$716.38 |
| Max. Negotiated Rate |
$1,345.04 |
| Rate for Payer: Aetna Commercial |
$1,315.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,257.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$774.86
|
| Rate for Payer: Cash Price |
$438.60
|
| Rate for Payer: Cigna Commercial |
$1,345.04
|
| Rate for Payer: Health EOS Commercial |
$1,301.18
|
| Rate for Payer: HFN Commercial |
$1,345.04
|
| Rate for Payer: Multiplan Commercial |
$1,169.60
|
| Rate for Payer: NAPHCARE Commercial |
$877.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,345.04
|
| Rate for Payer: Quartz Beloit One Network |
$716.38
|
| Rate for Payer: Quartz Commercial |
$877.20
|
| Rate for Payer: WEA Trust Commercial |
$804.10
|
| Rate for Payer: WPS Commercial |
$1,082.90
|
|
|
TEST LEAD INTERSTIM 306001
|
Facility
|
IP
|
$854.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$418.46 |
| Max. Negotiated Rate |
$785.68 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$512.40
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
TEST LEAD INTERSTIM 306001
|
Facility
|
OP
|
$854.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$239.12 |
| Max. Negotiated Rate |
$3,416.00 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Aetna Managed Medicare |
$239.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$409.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.90
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$640.50
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$555.10
|
| Rate for Payer: Quartz Medicare Advantage |
$512.40
|
| Rate for Payer: The Alliance Commercial |
$3,416.00
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
Testosterone Cypionate
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
5593764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.23
|
| Rate for Payer: Quartz Medicare Advantage |
$0.22
|
| Rate for Payer: The Alliance Commercial |
$1.44
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate
|
Professional
|
Both
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
5593764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: HFN Commercial |
$0.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: The Alliance Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicaid |
$0.01
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
5593764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.27
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.23
|
| Rate for Payer: Quartz Medicare Advantage |
$0.22
|
| Rate for Payer: The Alliance Commercial |
$1.44
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Professional
|
Both
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: HFN Commercial |
$0.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: The Alliance Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicaid |
$0.01
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.27
|
|
|
Testosterone Free
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$106.80
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Testosterone Free
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Aetna Managed Medicare |
$25.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.28
|
| Rate for Payer: Anthem Medicaid |
$26.32
|
| Rate for Payer: Anthem Medicare Advantage |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.47
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.61
|
| Rate for Payer: Dean Health Medicaid |
$26.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.47
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.47
|
| Rate for Payer: Managed Health Services Medicaid |
$27.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.47
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.47
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$38.20
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.32
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$115.70
|
| Rate for Payer: Quartz Medicare Advantage |
$25.47
|
| Rate for Payer: The Alliance Commercial |
$101.88
|
| Rate for Payer: United Healthcare Medicaid |
$26.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.47
|
| Rate for Payer: United Healthcare PPO |
$133.50
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: Wellcare Medicare |
$25.47
|
| Rate for Payer: WMAP Medicaid |
$26.32
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Testosterone Free
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.32 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Aetna Commercial |
$169.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$169.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.80
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$169.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.91
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.10
|
| Rate for Payer: Quartz Beloit One Network |
$78.32
|
| Rate for Payer: Quartz Commercial |
$101.46
|
| Rate for Payer: The Alliance Commercial |
$89.00
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Testosterone, Free, Bioavailable & Total
|
Professional
|
Both
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.11 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.60
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: HFN Commercial |
$309.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.11
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: The Alliance Commercial |
$163.00
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
