|
TPMT Amplification
|
Facility
|
IP
|
$181.00
|
|
| Hospital Charge Code |
2778838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.24 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$112.94
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
TPMT Amplification
|
Professional
|
Both
|
$181.00
|
|
| Hospital Charge Code |
2778838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.83 |
| Max. Negotiated Rate |
$178.83 |
| Rate for Payer: Aetna Commercial |
$178.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$178.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.94
|
| Rate for Payer: Health EOS Commercial |
$171.30
|
| Rate for Payer: HFN Commercial |
$178.83
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: Preferred Network Access Commercial |
$178.83
|
| Rate for Payer: Quartz Beloit One Network |
$82.83
|
| Rate for Payer: Quartz Commercial |
$107.30
|
| Rate for Payer: The Alliance Commercial |
$94.12
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
TPMT Amplification
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
2778838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.71 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Aetna Managed Medicare |
$52.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.34
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.18
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: NAPHCARE Commercial |
$112.94
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$122.36
|
| Rate for Payer: Quartz Medicare Advantage |
$112.94
|
| Rate for Payer: The Alliance Commercial |
$94.12
|
| Rate for Payer: United Healthcare PPO |
$141.18
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
TPMT Chromatography
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
2778839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.50 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$195.31
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
TPMT Chromatography
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
2778839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$211.59
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$244.14
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
TPMT Chromatography
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
2778839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$309.24 |
| Rate for Payer: Aetna Commercial |
$309.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$309.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$162.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$296.22
|
| Rate for Payer: HFN Commercial |
$309.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$309.24
|
| Rate for Payer: Quartz Beloit One Network |
$143.23
|
| Rate for Payer: Quartz Commercial |
$185.55
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
TPMT Enzyme Activity
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2778840
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.50 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$195.31
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
TPMT Enzyme Activity
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2778840
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.06 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$23.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$86.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.27
|
| Rate for Payer: Anthem Medicare Advantage |
$23.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.06
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23.06
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23.06
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$34.59
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$211.59
|
| Rate for Payer: Quartz Medicare Advantage |
$23.06
|
| Rate for Payer: The Alliance Commercial |
$92.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.06
|
| Rate for Payer: United Healthcare PPO |
$244.14
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: Wellcare Medicare |
$23.06
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
TPMT Enzyme Activity
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
2778840
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.06 |
| Max. Negotiated Rate |
$309.24 |
| Rate for Payer: Aetna Commercial |
$309.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$23.06
|
| Rate for Payer: Anthem Medicare Advantage |
$23.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.06
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$309.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$162.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.06
|
| Rate for Payer: Health EOS Commercial |
$296.22
|
| Rate for Payer: HFN Commercial |
$309.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.06
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$34.59
|
| Rate for Payer: Preferred Network Access Commercial |
$309.24
|
| Rate for Payer: Quartz Beloit One Network |
$143.23
|
| Rate for Payer: Quartz Commercial |
$185.55
|
| Rate for Payer: Quartz Medicare Advantage |
$23.06
|
| Rate for Payer: The Alliance Commercial |
$91.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.06
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$101.45
|
|
|
TPMT Interp & Report
|
Professional
|
Both
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.13 |
| Max. Negotiated Rate |
$43.47 |
| Rate for Payer: Aetna Commercial |
$43.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$43.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.46
|
| Rate for Payer: Health EOS Commercial |
$41.64
|
| Rate for Payer: HFN Commercial |
$43.47
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$43.47
|
| Rate for Payer: Quartz Beloit One Network |
$20.13
|
| Rate for Payer: Quartz Commercial |
$26.08
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMT Interp & Report
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: United Healthcare PPO |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMT Interp & Report
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2778843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMT Lysis
|
Facility
|
IP
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TPMT Lysis
|
Facility
|
OP
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.58
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: United Healthcare PPO |
$47.58
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TPMT Lysis
|
Professional
|
Both
|
$61.00
|
|
| Hospital Charge Code |
2778844
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$60.27 |
| Rate for Payer: Aetna Commercial |
$60.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.06
|
| Rate for Payer: Health EOS Commercial |
$57.73
|
| Rate for Payer: HFN Commercial |
$60.27
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$60.27
|
| Rate for Payer: Quartz Beloit One Network |
$27.91
|
| Rate for Payer: Quartz Commercial |
$36.16
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TPMT Nucleic Acid Probe
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: United Healthcare PPO |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMT Nucleic Acid Probe
|
Professional
|
Both
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.13 |
| Max. Negotiated Rate |
$43.47 |
| Rate for Payer: Aetna Commercial |
$43.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$43.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.46
|
| Rate for Payer: Health EOS Commercial |
$41.64
|
| Rate for Payer: HFN Commercial |
$43.47
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$43.47
|
| Rate for Payer: Quartz Beloit One Network |
$20.13
|
| Rate for Payer: Quartz Commercial |
$26.08
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMT Nucleic Acid Probe
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2778848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
TPMY Lysis
|
Facility
|
IP
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TPMY Lysis
|
Facility
|
OP
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.58
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: United Healthcare PPO |
$47.58
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TPMY Lysis
|
Professional
|
Both
|
$61.00
|
|
| Hospital Charge Code |
2778849
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$60.27 |
| Rate for Payer: Aetna Commercial |
$60.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$60.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.06
|
| Rate for Payer: Health EOS Commercial |
$57.73
|
| Rate for Payer: HFN Commercial |
$60.27
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$60.27
|
| Rate for Payer: Quartz Beloit One Network |
$27.91
|
| Rate for Payer: Quartz Commercial |
$36.16
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
TRABECULECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960447
|
|
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
|
|
|
TRABECULECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960447
|
|
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
|
|
|
Trabeculoplasty By Laser; 1 or more sessions
|
Professional
|
Both
|
$1,298.00
|
|
|
Service Code
|
CPT 65855
|
| Hospital Charge Code |
1188907
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$1,282.42 |
| Rate for Payer: Aetna Commercial |
$1,282.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,160.93
|
| Rate for Payer: Aetna Managed Medicare |
$170.02
|
| Rate for Payer: Anthem Medicare Advantage |
$170.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$170.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$170.02
|
| Rate for Payer: Cash Price |
$389.40
|
| Rate for Payer: Cash Price |
$389.40
|
| Rate for Payer: Cash Price |
$389.40
|
| Rate for Payer: Cigna Commercial |
$1,282.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$170.02
|
| Rate for Payer: Health EOS Commercial |
$1,228.43
|
| Rate for Payer: HFN Commercial |
$1,282.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$719.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$170.02
|
| Rate for Payer: Multiplan Commercial |
$1,079.94
|
| Rate for Payer: NAPHCARE Commercial |
$255.03
|
| Rate for Payer: Preferred Network Access Commercial |
$1,282.42
|
| Rate for Payer: Quartz Beloit One Network |
$593.96
|
| Rate for Payer: Quartz Commercial |
$769.45
|
| Rate for Payer: Quartz Medicare Advantage |
$170.02
|
| Rate for Payer: The Alliance Commercial |
$722.58
|
| Rate for Payer: United Healthcare Medicaid |
$279.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$170.02
|
| Rate for Payer: WEA Trust Commercial |
$742.46
|
| Rate for Payer: WPS Commercial |
$765.09
|
|
|
Trabeculoplasty By Laser; 1 or more sessions 6585550
|
Professional
|
Both
|
$2,594.00
|
|
|
Service Code
|
CPT 65855 50
|
| Hospital Charge Code |
5547178
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$279.78 |
| Max. Negotiated Rate |
$2,562.87 |
| Rate for Payer: Aetna Commercial |
$2,562.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,320.07
|
| Rate for Payer: Cash Price |
$778.20
|
| Rate for Payer: Cash Price |
$778.20
|
| Rate for Payer: Cash Price |
$778.20
|
| Rate for Payer: Cigna Commercial |
$2,562.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,618.66
|
| Rate for Payer: Health EOS Commercial |
$2,454.96
|
| Rate for Payer: HFN Commercial |
$2,562.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$719.67
|
| Rate for Payer: Multiplan Commercial |
$2,158.21
|
| Rate for Payer: Preferred Network Access Commercial |
$2,562.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,187.01
|
| Rate for Payer: Quartz Commercial |
$1,537.72
|
| Rate for Payer: The Alliance Commercial |
$1,348.88
|
| Rate for Payer: United Healthcare Medicaid |
$279.78
|
| Rate for Payer: WEA Trust Commercial |
$1,483.77
|
| Rate for Payer: WPS Commercial |
$1,998.16
|
|
