|
TENSION FREE VAGINAL TAPE PROCEDURE
|
Facility
|
OP
|
$4,721.00
|
|
| Hospital Charge Code |
2960460
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,374.76 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,374.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,191.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,454.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,356.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,747.62
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,682.38
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: NAPHCARE Commercial |
$2,945.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$3,191.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,945.90
|
| Rate for Payer: The Alliance Commercial |
$2,454.92
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
TENSION FREE VAGINAL TAPE PROCEDURE
|
Facility
|
IP
|
$4,721.00
|
|
| Hospital Charge Code |
2960460
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,405.82 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$2,945.90
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
TENSOGRIP SIZE F #A938-11
|
Facility
|
IP
|
$891.00
|
|
| Hospital Charge Code |
2974062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$454.05 |
| Max. Negotiated Rate |
$852.51 |
| Rate for Payer: Aetna Commercial |
$833.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$491.12
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$852.51
|
| Rate for Payer: Health EOS Commercial |
$824.71
|
| Rate for Payer: HFN Commercial |
$852.51
|
| Rate for Payer: Multiplan Commercial |
$741.31
|
| Rate for Payer: Preferred Network Access Commercial |
$852.51
|
| Rate for Payer: Quartz Beloit One Network |
$454.05
|
| Rate for Payer: Quartz Commercial |
$555.98
|
| Rate for Payer: WEA Trust Commercial |
$509.65
|
| Rate for Payer: WPS Commercial |
$686.34
|
|
|
TENSOGRIP SIZE F #A938-11
|
Facility
|
OP
|
$891.00
|
|
| Hospital Charge Code |
2974062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$259.46 |
| Max. Negotiated Rate |
$852.51 |
| Rate for Payer: Aetna Commercial |
$833.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.91
|
| Rate for Payer: Aetna Managed Medicare |
$259.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$602.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$463.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$444.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$491.12
|
| Rate for Payer: Cash Price |
$267.30
|
| Rate for Payer: Cigna Commercial |
$852.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$518.56
|
| Rate for Payer: Health EOS Commercial |
$824.71
|
| Rate for Payer: HFN Commercial |
$852.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$694.98
|
| Rate for Payer: Multiplan Commercial |
$741.31
|
| Rate for Payer: NAPHCARE Commercial |
$555.98
|
| Rate for Payer: Preferred Network Access Commercial |
$852.51
|
| Rate for Payer: Quartz Beloit One Network |
$454.05
|
| Rate for Payer: Quartz Commercial |
$602.32
|
| Rate for Payer: Quartz Medicare Advantage |
$555.98
|
| Rate for Payer: The Alliance Commercial |
$463.32
|
| Rate for Payer: WEA Trust Commercial |
$509.65
|
| Rate for Payer: WPS Commercial |
$686.34
|
|
|
TEST CABLE INTERSTIM 357501
|
Facility
|
OP
|
$854.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5384755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.68 |
| Max. Negotiated Rate |
$817.11 |
| Rate for Payer: Aetna Commercial |
$799.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.82
|
| Rate for Payer: Aetna Managed Medicare |
$248.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.72
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$817.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$497.03
|
| Rate for Payer: Health EOS Commercial |
$790.46
|
| Rate for Payer: HFN Commercial |
$817.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.12
|
| Rate for Payer: Multiplan Commercial |
$710.53
|
| Rate for Payer: NAPHCARE Commercial |
$532.90
|
| Rate for Payer: Preferred Network Access Commercial |
$817.11
|
| Rate for Payer: Quartz Beloit One Network |
$435.20
|
| Rate for Payer: Quartz Commercial |
$577.30
|
| Rate for Payer: Quartz Medicare Advantage |
$532.90
|
| Rate for Payer: The Alliance Commercial |
$444.08
|
| Rate for Payer: WEA Trust Commercial |
$488.49
|
| Rate for Payer: WPS Commercial |
$657.84
|
|
|
TEST CABLE INTERSTIM 357501
|
Facility
|
IP
|
$854.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5384755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$435.20 |
| Max. Negotiated Rate |
$817.11 |
| Rate for Payer: Aetna Commercial |
$799.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.72
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$817.11
|
| Rate for Payer: Health EOS Commercial |
$790.46
|
| Rate for Payer: HFN Commercial |
$817.11
|
| Rate for Payer: Multiplan Commercial |
$710.53
|
| Rate for Payer: Preferred Network Access Commercial |
$817.11
|
| Rate for Payer: Quartz Beloit One Network |
$435.20
|
| Rate for Payer: Quartz Commercial |
$532.90
|
| Rate for Payer: WEA Trust Commercial |
$488.49
|
| Rate for Payer: WPS Commercial |
$657.84
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$59,030.40
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$16,464.94 |
| Max. Negotiated Rate |
$59,030.40 |
| Rate for Payer: Aetna Managed Medicare |
$16,464.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45,466.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,849.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33,109.75
|
| Rate for Payer: Anthem Medicare Advantage |
$16,464.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,464.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,464.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,464.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,754.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,464.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43,052.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,464.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,464.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,464.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,464.94
|
| Rate for Payer: NAPHCARE Commercial |
$24,697.41
|
| Rate for Payer: Quartz Medicare Advantage |
$16,464.94
|
| Rate for Payer: The Alliance Commercial |
$59,030.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,464.94
|
| Rate for Payer: United Healthcare PPO |
$33,516.85
|
| Rate for Payer: Wellcare Medicare |
$16,464.94
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$33,191.60
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$8,928.50 |
| Max. Negotiated Rate |
$33,191.60 |
| Rate for Payer: Anthem Medicare Advantage |
$8,928.50
|
| Rate for Payer: Aetna Managed Medicare |
$8,928.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,994.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,391.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,473.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,928.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,928.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,928.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,396.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,928.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,100.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,928.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,928.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,928.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,928.50
|
| Rate for Payer: NAPHCARE Commercial |
$13,392.76
|
| Rate for Payer: Quartz Medicare Advantage |
$8,928.50
|
| Rate for Payer: The Alliance Commercial |
$33,191.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,928.50
|
| Rate for Payer: United Healthcare PPO |
$18,762.74
|
| Rate for Payer: Wellcare Medicare |
$8,928.50
|
|
|
TESTICLE, TORSION OF
|
Facility
|
IP
|
$1,048.00
|
|
| Hospital Charge Code |
2960439
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$534.06 |
| Max. Negotiated Rate |
$1,002.73 |
| Rate for Payer: Aetna Commercial |
$980.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$937.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.66
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$1,002.73
|
| Rate for Payer: Health EOS Commercial |
$970.03
|
| Rate for Payer: HFN Commercial |
$1,002.73
|
| Rate for Payer: Multiplan Commercial |
$871.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,002.73
|
| Rate for Payer: Quartz Beloit One Network |
$534.06
|
| Rate for Payer: Quartz Commercial |
$653.95
|
| Rate for Payer: WEA Trust Commercial |
$599.46
|
| Rate for Payer: WPS Commercial |
$807.27
|
|
|
TESTICLE, TORSION OF
|
Facility
|
OP
|
$1,048.00
|
|
| Hospital Charge Code |
2960439
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$305.18 |
| Max. Negotiated Rate |
$1,002.73 |
| Rate for Payer: Aetna Commercial |
$980.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$937.33
|
| Rate for Payer: Aetna Managed Medicare |
$305.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$708.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$523.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.66
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cigna Commercial |
$1,002.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$609.94
|
| Rate for Payer: Health EOS Commercial |
$970.03
|
| Rate for Payer: HFN Commercial |
$1,002.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$817.44
|
| Rate for Payer: Multiplan Commercial |
$871.94
|
| Rate for Payer: NAPHCARE Commercial |
$653.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,002.73
|
| Rate for Payer: Quartz Beloit One Network |
$534.06
|
| Rate for Payer: Quartz Commercial |
$708.45
|
| Rate for Payer: Quartz Medicare Advantage |
$653.95
|
| Rate for Payer: The Alliance Commercial |
$544.96
|
| Rate for Payer: WEA Trust Commercial |
$599.46
|
| Rate for Payer: WPS Commercial |
$807.27
|
|
|
TESTICULAR AND EPIDIDYMAL PROCEDURES
|
Facility
|
OP
|
$620.49
|
|
|
Service Code
|
EAPG 00180
|
| Min. Negotiated Rate |
$596.63 |
| Max. Negotiated Rate |
$620.49 |
| Rate for Payer: Anthem Medicaid |
$596.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$596.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$596.63
|
| Rate for Payer: Dean Health Medicaid |
$596.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$596.63
|
| Rate for Payer: Managed Health Services Medicaid |
$620.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.63
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$596.63
|
| Rate for Payer: United Healthcare Medicaid |
$596.63
|
|
|
TESTICULAR PROSTHESIS INSERTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960326
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
TESTICULAR PROSTHESIS INSERTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960326
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
TEST KIT INTERSTIM 309201
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349488
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$425.73 |
| Max. Negotiated Rate |
$1,398.84 |
| Rate for Payer: Aetna Commercial |
$1,368.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,307.61
|
| Rate for Payer: Aetna Managed Medicare |
$425.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$988.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$760.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$729.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$805.85
|
| Rate for Payer: Cash Price |
$438.60
|
| Rate for Payer: Cigna Commercial |
$1,398.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$850.88
|
| Rate for Payer: Health EOS Commercial |
$1,353.23
|
| Rate for Payer: HFN Commercial |
$1,398.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,140.36
|
| Rate for Payer: Multiplan Commercial |
$1,216.38
|
| Rate for Payer: NAPHCARE Commercial |
$912.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.84
|
| Rate for Payer: Quartz Beloit One Network |
$745.04
|
| Rate for Payer: Quartz Commercial |
$988.31
|
| Rate for Payer: Quartz Medicare Advantage |
$912.29
|
| Rate for Payer: The Alliance Commercial |
$760.24
|
| Rate for Payer: WEA Trust Commercial |
$836.26
|
| Rate for Payer: WPS Commercial |
$1,126.18
|
|
|
TEST KIT INTERSTIM 309201
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349488
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$745.04 |
| Max. Negotiated Rate |
$1,398.84 |
| Rate for Payer: Aetna Commercial |
$1,368.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,307.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$805.85
|
| Rate for Payer: Cash Price |
$438.60
|
| Rate for Payer: Cigna Commercial |
$1,398.84
|
| Rate for Payer: Health EOS Commercial |
$1,353.23
|
| Rate for Payer: HFN Commercial |
$1,398.84
|
| Rate for Payer: Multiplan Commercial |
$1,216.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,398.84
|
| Rate for Payer: Quartz Beloit One Network |
$745.04
|
| Rate for Payer: Quartz Commercial |
$912.29
|
| Rate for Payer: WEA Trust Commercial |
$836.26
|
| Rate for Payer: WPS Commercial |
$1,126.18
|
|
|
TEST LEAD INTERSTIM 306001
|
Facility
|
OP
|
$854.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.68 |
| Max. Negotiated Rate |
$817.11 |
| Rate for Payer: Aetna Commercial |
$799.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.82
|
| Rate for Payer: Aetna Managed Medicare |
$248.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.72
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$817.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$497.03
|
| Rate for Payer: Health EOS Commercial |
$790.46
|
| Rate for Payer: HFN Commercial |
$817.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.12
|
| Rate for Payer: Multiplan Commercial |
$710.53
|
| Rate for Payer: NAPHCARE Commercial |
$532.90
|
| Rate for Payer: Preferred Network Access Commercial |
$817.11
|
| Rate for Payer: Quartz Beloit One Network |
$435.20
|
| Rate for Payer: Quartz Commercial |
$577.30
|
| Rate for Payer: Quartz Medicare Advantage |
$532.90
|
| Rate for Payer: The Alliance Commercial |
$444.08
|
| Rate for Payer: WEA Trust Commercial |
$488.49
|
| Rate for Payer: WPS Commercial |
$657.84
|
|
|
TEST LEAD INTERSTIM 306001
|
Facility
|
IP
|
$854.00
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
5349489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$435.20 |
| Max. Negotiated Rate |
$817.11 |
| Rate for Payer: Aetna Commercial |
$799.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.72
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$817.11
|
| Rate for Payer: Health EOS Commercial |
$790.46
|
| Rate for Payer: HFN Commercial |
$817.11
|
| Rate for Payer: Multiplan Commercial |
$710.53
|
| Rate for Payer: Preferred Network Access Commercial |
$817.11
|
| Rate for Payer: Quartz Beloit One Network |
$435.20
|
| Rate for Payer: Quartz Commercial |
$532.90
|
| Rate for Payer: WEA Trust Commercial |
$488.49
|
| Rate for Payer: WPS Commercial |
$657.84
|
|
|
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 |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| 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 |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.24
|
| Rate for Payer: Quartz Medicare Advantage |
$0.22
|
| Rate for Payer: The Alliance Commercial |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| 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 |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Managed Medicare |
$0.03
|
| Rate for Payer: Anthem Medicare Advantage |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.34
|
| Rate for Payer: HFN Commercial |
$0.36
|
| 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: Independent Care Health Plan Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: NAPHCARE Commercial |
$0.05
|
| Rate for Payer: Preferred Network Access Commercial |
$0.36
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: Quartz Medicare Advantage |
$0.03
|
| Rate for Payer: The Alliance Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicaid |
$0.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.03
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| 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 |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: HFN Commercial |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| Rate for Payer: WPS Commercial |
$0.28
|
|
|
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 |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Managed Medicare |
$0.03
|
| Rate for Payer: Anthem Medicare Advantage |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.34
|
| Rate for Payer: HFN Commercial |
$0.36
|
| 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: Independent Care Health Plan Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: NAPHCARE Commercial |
$0.05
|
| Rate for Payer: Preferred Network Access Commercial |
$0.36
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: Quartz Medicare Advantage |
$0.03
|
| Rate for Payer: The Alliance Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicaid |
$0.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.03
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| 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 |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: HFN Commercial |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| Rate for Payer: WPS Commercial |
$0.28
|
|
|
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 |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.32
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| 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 |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.24
|
| Rate for Payer: Quartz Medicare Advantage |
$0.22
|
| Rate for Payer: The Alliance Commercial |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$0.21
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Free
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
Testosterone Free
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.49 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$26.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.97
|
| Rate for Payer: Anthem Medicare Advantage |
$26.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.49
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$26.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$26.49
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$26.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$26.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$26.49
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$39.73
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$26.49
|
| Rate for Payer: The Alliance Commercial |
$105.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.49
|
| Rate for Payer: United Healthcare PPO |
$138.84
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: Wellcare Medicare |
$26.49
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
