|
Trichrome Stain Report
|
Professional
|
$135.00
|
|
|
Service Code
|
CPT 87209
|
| Hospital Charge Code |
634215
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$17.98 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna Commercial |
$128.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.10
|
| Rate for Payer: Aetna Managed Medicare |
$17.98
|
| Rate for Payer: Anthem Medicare Advantage |
$17.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.98
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$128.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.98
|
| Rate for Payer: Health EOS Commercial |
$122.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.98
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.25
|
| Rate for Payer: Quartz Beloit One Network |
$59.40
|
| Rate for Payer: Quartz Commercial |
$76.95
|
| Rate for Payer: Quartz Medicare Advantage |
$17.98
|
| Rate for Payer: The Alliance Commercial |
$71.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.98
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$79.11
|
|
|
TRICUSPID RING 26MM TRI-AD #900SFC-26
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 26MM TRI-AD #900SFC-26
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 28MM TRI-AD 900SFC-28
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 28MM TRI-AD 900SFC-28
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973914
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 30MM TRI-AD #900SFC-30
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973915
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 30MM TRI-AD #900SFC-30
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973915
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 32MM TRI-AD #900SFC-32
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 32MM TRI-AD #900SFC-32
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 34MM TRI-AD #900SFC-34
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 34MM TRI-AD #900SFC-34
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973917
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 36MM TRI-AD #900SFC-36
|
Facility
OP
|
$15,864.00
|
|
| Hospital Charge Code |
2973918
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$63,456.00 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: The Alliance Commercial |
$63,456.00
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
TRICUSPID RING 36MM TRI-AD #900SFC-36
|
Facility
IP
|
$15,864.00
|
|
| Hospital Charge Code |
2973918
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
Tricyclic Antidepressants ID & Quant, Serum
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
CPT 80337
|
| Hospital Charge Code |
4075935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$35.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.75
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$75.00
|
| Rate for Payer: United Healthcare PPO |
$93.75
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
Tricyclic Antidepressants ID & Quant, Serum
|
Professional
|
$125.00
|
|
|
Service Code
|
CPT 80337
|
| Hospital Charge Code |
4075935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.54 |
| Max. Negotiated Rate |
$118.75 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$118.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.00
|
| Rate for Payer: Health EOS Commercial |
$113.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.54
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: Preferred Network Access Commercial |
$118.75
|
| Rate for Payer: Quartz Beloit One Network |
$55.00
|
| Rate for Payer: Quartz Commercial |
$71.25
|
| Rate for Payer: The Alliance Commercial |
$62.50
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
Tricyclic Antidepressants ID & Quant, Serum
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 80337
|
| Hospital Charge Code |
4075935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
Tricyclic Antidepressants, Quant, Urine
|
Facility
IP
|
$265.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983429
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$129.85 |
| Max. Negotiated Rate |
$243.80 |
| Rate for Payer: Aetna Commercial |
$238.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.45
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$243.80
|
| Rate for Payer: Health EOS Commercial |
$235.85
|
| Rate for Payer: HFN Commercial |
$243.80
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: NAPHCARE Commercial |
$159.00
|
| Rate for Payer: Preferred Network Access Commercial |
$243.80
|
| Rate for Payer: Quartz Beloit One Network |
$129.85
|
| Rate for Payer: Quartz Commercial |
$159.00
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Tricyclic Antidepressants, Quant, Urine
|
Facility
OP
|
$265.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983429
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.20 |
| Max. Negotiated Rate |
$243.80 |
| Rate for Payer: Aetna Commercial |
$238.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.90
|
| Rate for Payer: Aetna Managed Medicare |
$74.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$132.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.45
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$243.80
|
| Rate for Payer: Health EOS Commercial |
$235.85
|
| Rate for Payer: HFN Commercial |
$243.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.75
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: NAPHCARE Commercial |
$159.00
|
| Rate for Payer: Preferred Network Access Commercial |
$243.80
|
| Rate for Payer: Quartz Beloit One Network |
$129.85
|
| Rate for Payer: Quartz Commercial |
$172.25
|
| Rate for Payer: Quartz Medicare Advantage |
$159.00
|
| Rate for Payer: United Healthcare PPO |
$198.75
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Tricyclic Antidepressants, Quant, Urine
|
Professional
|
$265.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
983429
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$251.75 |
| Rate for Payer: Aetna Commercial |
$251.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.90
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$251.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.00
|
| Rate for Payer: Health EOS Commercial |
$241.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: Preferred Network Access Commercial |
$251.75
|
| Rate for Payer: Quartz Beloit One Network |
$116.60
|
| Rate for Payer: Quartz Commercial |
$151.05
|
| Rate for Payer: The Alliance Commercial |
$132.50
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Tricyclic Antidepressants Screen
|
Facility
OP
|
$48.00
|
|
| Hospital Charge Code |
2942886
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: United Healthcare PPO |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Tricyclic Antidepressants Screen
|
Professional
|
$48.00
|
|
| Hospital Charge Code |
2942886
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.80
|
| Rate for Payer: Health EOS Commercial |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.60
|
| Rate for Payer: Quartz Beloit One Network |
$21.12
|
| Rate for Payer: Quartz Commercial |
$27.36
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Tricyclic Antidepressants Screen
|
Facility
IP
|
$48.00
|
|
| Hospital Charge Code |
2942886
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
TRIGGER FINGER RELEASE
|
Facility
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2960453
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$655.13 |
| Max. Negotiated Rate |
$1,230.04 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$802.20
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
TRIGGER FINGER RELEASE
|
Facility
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2960453
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$374.36 |
| Max. Negotiated Rate |
$5,348.00 |
| Rate for Payer: Aetna Commercial |
$1,203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,149.82
|
| Rate for Payer: Aetna Managed Medicare |
$374.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$869.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.61
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,230.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$748.19
|
| Rate for Payer: Health EOS Commercial |
$1,189.93
|
| Rate for Payer: HFN Commercial |
$1,230.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.75
|
| Rate for Payer: Multiplan Commercial |
$1,069.60
|
| Rate for Payer: NAPHCARE Commercial |
$802.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,230.04
|
| Rate for Payer: Quartz Beloit One Network |
$655.13
|
| Rate for Payer: Quartz Commercial |
$869.05
|
| Rate for Payer: Quartz Medicare Advantage |
$802.20
|
| Rate for Payer: The Alliance Commercial |
$5,348.00
|
| Rate for Payer: WEA Trust Commercial |
$735.35
|
| Rate for Payer: WPS Commercial |
$990.32
|
|
|
TRIGGER POINT INJECTION, PAIN
|
Facility
OP
|
$291.00
|
|
| Hospital Charge Code |
2960454
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$81.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$218.25
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$174.60
|
| Rate for Payer: The Alliance Commercial |
$1,164.00
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
