|
TIP VITAL VUE 8886828306
|
Facility
|
IP
|
$2,182.00
|
|
| Hospital Charge Code |
2965537
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,111.95 |
| Max. Negotiated Rate |
$2,087.74 |
| Rate for Payer: Aetna Commercial |
$2,042.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,951.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,202.72
|
| Rate for Payer: Cash Price |
$654.60
|
| Rate for Payer: Cigna Commercial |
$2,087.74
|
| Rate for Payer: Health EOS Commercial |
$2,019.66
|
| Rate for Payer: HFN Commercial |
$2,087.74
|
| Rate for Payer: Multiplan Commercial |
$1,815.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,087.74
|
| Rate for Payer: Quartz Beloit One Network |
$1,111.95
|
| Rate for Payer: Quartz Commercial |
$1,361.57
|
| Rate for Payer: WEA Trust Commercial |
$1,248.10
|
| Rate for Payer: WPS Commercial |
$1,680.79
|
|
|
TIP VITAL VUE 8886828306
|
Facility
|
OP
|
$2,182.00
|
|
| Hospital Charge Code |
2965537
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$635.40 |
| Max. Negotiated Rate |
$2,087.74 |
| Rate for Payer: Aetna Commercial |
$2,042.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,951.58
|
| Rate for Payer: Aetna Managed Medicare |
$635.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,475.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,134.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,089.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,202.72
|
| Rate for Payer: Cash Price |
$654.60
|
| Rate for Payer: Cigna Commercial |
$2,087.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,269.92
|
| Rate for Payer: Health EOS Commercial |
$2,019.66
|
| Rate for Payer: HFN Commercial |
$2,087.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,701.96
|
| Rate for Payer: Multiplan Commercial |
$1,815.42
|
| Rate for Payer: NAPHCARE Commercial |
$1,361.57
|
| Rate for Payer: Preferred Network Access Commercial |
$2,087.74
|
| Rate for Payer: Quartz Beloit One Network |
$1,111.95
|
| Rate for Payer: Quartz Commercial |
$1,475.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1,361.57
|
| Rate for Payer: The Alliance Commercial |
$1,134.64
|
| Rate for Payer: WEA Trust Commercial |
$1,248.10
|
| Rate for Payer: WPS Commercial |
$1,680.79
|
|
|
TISSEEL FIBRIN SEALANT 10ML 1501263 (MED)
|
Facility
|
OP
|
$4,984.00
|
|
| Hospital Charge Code |
4294559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.34 |
| Max. Negotiated Rate |
$4,768.69 |
| Rate for Payer: Aetna Commercial |
$4,665.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,457.69
|
| Rate for Payer: Aetna Managed Medicare |
$1,451.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,369.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,591.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,488.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,747.18
|
| Rate for Payer: Cash Price |
$1,495.20
|
| Rate for Payer: Cigna Commercial |
$4,768.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,900.69
|
| Rate for Payer: Health EOS Commercial |
$4,613.19
|
| Rate for Payer: HFN Commercial |
$4,768.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,887.52
|
| Rate for Payer: Multiplan Commercial |
$4,146.69
|
| Rate for Payer: NAPHCARE Commercial |
$3,110.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,768.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.85
|
| Rate for Payer: Quartz Commercial |
$3,369.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,110.02
|
| Rate for Payer: The Alliance Commercial |
$2,591.68
|
| Rate for Payer: WEA Trust Commercial |
$2,850.85
|
| Rate for Payer: WPS Commercial |
$3,839.18
|
|
|
TISSEEL FIBRIN SEALANT 10ML 1501263 (MED)
|
Facility
|
IP
|
$4,984.00
|
|
| Hospital Charge Code |
4294559
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,539.85 |
| Max. Negotiated Rate |
$4,768.69 |
| Rate for Payer: Aetna Commercial |
$4,665.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,457.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,747.18
|
| Rate for Payer: Cash Price |
$1,495.20
|
| Rate for Payer: Cigna Commercial |
$4,768.69
|
| Rate for Payer: Health EOS Commercial |
$4,613.19
|
| Rate for Payer: HFN Commercial |
$4,768.69
|
| Rate for Payer: Multiplan Commercial |
$4,146.69
|
| Rate for Payer: Preferred Network Access Commercial |
$4,768.69
|
| Rate for Payer: Quartz Beloit One Network |
$2,539.85
|
| Rate for Payer: Quartz Commercial |
$3,110.02
|
| Rate for Payer: WEA Trust Commercial |
$2,850.85
|
| Rate for Payer: WPS Commercial |
$3,839.18
|
|
|
TISSEEL FIBRIN SEALANT 4ML 1501262 (MED)
|
Facility
|
OP
|
$2,707.00
|
|
| Hospital Charge Code |
4294557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$788.28 |
| Max. Negotiated Rate |
$2,590.06 |
| Rate for Payer: Aetna Commercial |
$2,533.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,421.14
|
| Rate for Payer: Aetna Managed Medicare |
$788.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,829.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,407.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,351.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,492.10
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cigna Commercial |
$2,590.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,575.47
|
| Rate for Payer: Health EOS Commercial |
$2,505.60
|
| Rate for Payer: HFN Commercial |
$2,590.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,111.46
|
| Rate for Payer: Multiplan Commercial |
$2,252.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,689.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,590.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,379.49
|
| Rate for Payer: Quartz Commercial |
$1,829.93
|
| Rate for Payer: Quartz Medicare Advantage |
$1,689.17
|
| Rate for Payer: The Alliance Commercial |
$1,407.64
|
| Rate for Payer: WEA Trust Commercial |
$1,548.40
|
| Rate for Payer: WPS Commercial |
$2,085.20
|
|
|
TISSEEL FIBRIN SEALANT 4ML 1501262 (MED)
|
Facility
|
IP
|
$2,707.00
|
|
| Hospital Charge Code |
4294557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,379.49 |
| Max. Negotiated Rate |
$2,590.06 |
| Rate for Payer: Aetna Commercial |
$2,533.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,421.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,492.10
|
| Rate for Payer: Cash Price |
$812.10
|
| Rate for Payer: Cigna Commercial |
$2,590.06
|
| Rate for Payer: Health EOS Commercial |
$2,505.60
|
| Rate for Payer: HFN Commercial |
$2,590.06
|
| Rate for Payer: Multiplan Commercial |
$2,252.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,590.06
|
| Rate for Payer: Quartz Beloit One Network |
$1,379.49
|
| Rate for Payer: Quartz Commercial |
$1,689.17
|
| Rate for Payer: WEA Trust Commercial |
$1,548.40
|
| Rate for Payer: WPS Commercial |
$2,085.20
|
|
|
Tissue Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$8.96
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Tissue Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$39.45
|
|
|
Tissue Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Tissue Culture, Bone Marrow
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
3313614
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.21 |
| Max. Negotiated Rate |
$657.80 |
| Rate for Payer: Aetna Commercial |
$216.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$149.50
|
| Rate for Payer: Anthem Medicare Advantage |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$149.50
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$216.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.50
|
| Rate for Payer: Health EOS Commercial |
$207.26
|
| Rate for Payer: HFN Commercial |
$216.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$527.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$527.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$224.25
|
| Rate for Payer: Preferred Network Access Commercial |
$216.37
|
| Rate for Payer: Quartz Beloit One Network |
$100.21
|
| Rate for Payer: Quartz Commercial |
$129.82
|
| Rate for Payer: Quartz Medicare Advantage |
$149.50
|
| Rate for Payer: The Alliance Commercial |
$590.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.50
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$657.80
|
|
|
Tissue Culture, Bone Marrow
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
3313614
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$209.54 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$136.66
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Tissue Culture, Bone Marrow
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
3313614
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$598.00 |
| Rate for Payer: Aetna Commercial |
$204.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.87
|
| Rate for Payer: Aetna Managed Medicare |
$149.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$560.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.17
|
| Rate for Payer: Anthem Medicare Advantage |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$149.50
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cigna Commercial |
$209.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$149.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$149.50
|
| Rate for Payer: Health EOS Commercial |
$202.71
|
| Rate for Payer: HFN Commercial |
$209.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$556.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$149.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$149.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$149.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$182.21
|
| Rate for Payer: NAPHCARE Commercial |
$224.25
|
| Rate for Payer: Preferred Network Access Commercial |
$209.54
|
| Rate for Payer: Quartz Beloit One Network |
$111.60
|
| Rate for Payer: Quartz Commercial |
$148.04
|
| Rate for Payer: Quartz Medicare Advantage |
$149.50
|
| Rate for Payer: The Alliance Commercial |
$598.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.50
|
| Rate for Payer: United Healthcare PPO |
$170.82
|
| Rate for Payer: WEA Trust Commercial |
$125.27
|
| Rate for Payer: Wellcare Medicare |
$149.50
|
| Rate for Payer: WPS Commercial |
$168.70
|
|
|
Tissue Culture for Neo
|
Facility
|
IP
|
$1,355.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
2778836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$690.51 |
| Max. Negotiated Rate |
$1,296.46 |
| Rate for Payer: Aetna Commercial |
$1,268.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,211.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.88
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: Health EOS Commercial |
$1,254.19
|
| Rate for Payer: HFN Commercial |
$1,296.46
|
| Rate for Payer: Multiplan Commercial |
$1,127.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,296.46
|
| Rate for Payer: Quartz Beloit One Network |
$690.51
|
| Rate for Payer: Quartz Commercial |
$845.52
|
| Rate for Payer: WEA Trust Commercial |
$775.06
|
| Rate for Payer: WPS Commercial |
$1,043.76
|
|
|
Tissue Culture for Neo
|
Professional
|
Both
|
$1,355.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
2778836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.50 |
| Max. Negotiated Rate |
$1,338.74 |
| Rate for Payer: Aetna Commercial |
$1,338.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,211.91
|
| Rate for Payer: Aetna Managed Medicare |
$149.50
|
| Rate for Payer: Anthem Medicare Advantage |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$149.50
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cigna Commercial |
$1,338.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$704.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.50
|
| Rate for Payer: Health EOS Commercial |
$1,282.37
|
| Rate for Payer: HFN Commercial |
$1,338.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$527.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$527.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$1,127.36
|
| Rate for Payer: NAPHCARE Commercial |
$224.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,338.74
|
| Rate for Payer: Quartz Beloit One Network |
$620.05
|
| Rate for Payer: Quartz Commercial |
$803.24
|
| Rate for Payer: Quartz Medicare Advantage |
$149.50
|
| Rate for Payer: The Alliance Commercial |
$590.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.50
|
| Rate for Payer: WEA Trust Commercial |
$775.06
|
| Rate for Payer: WPS Commercial |
$657.80
|
|
|
Tissue Culture for Neo
|
Facility
|
OP
|
$1,355.00
|
|
|
Service Code
|
CPT 88237
|
| Hospital Charge Code |
2778836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.50 |
| Max. Negotiated Rate |
$1,296.46 |
| Rate for Payer: Aetna Commercial |
$1,268.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,211.91
|
| Rate for Payer: Aetna Managed Medicare |
$149.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$560.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.17
|
| Rate for Payer: Anthem Medicare Advantage |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$149.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$149.50
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$149.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$788.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$149.50
|
| Rate for Payer: Health EOS Commercial |
$1,254.19
|
| Rate for Payer: HFN Commercial |
$1,296.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$556.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$149.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$149.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$149.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$149.50
|
| Rate for Payer: Multiplan Commercial |
$1,127.36
|
| Rate for Payer: NAPHCARE Commercial |
$224.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,296.46
|
| Rate for Payer: Quartz Beloit One Network |
$690.51
|
| Rate for Payer: Quartz Commercial |
$915.98
|
| Rate for Payer: Quartz Medicare Advantage |
$149.50
|
| Rate for Payer: The Alliance Commercial |
$598.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$149.50
|
| Rate for Payer: United Healthcare PPO |
$1,056.90
|
| Rate for Payer: WEA Trust Commercial |
$775.06
|
| Rate for Payer: Wellcare Medicare |
$149.50
|
| Rate for Payer: WPS Commercial |
$1,043.76
|
|
|
Tissue Culture, Non-Neo, Lympho
|
Professional
|
Both
|
$1,426.00
|
|
|
Service Code
|
CPT 88230
|
| Hospital Charge Code |
2778837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.15 |
| Max. Negotiated Rate |
$1,408.89 |
| Rate for Payer: Aetna Commercial |
$1,408.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,275.41
|
| Rate for Payer: Aetna Managed Medicare |
$121.15
|
| Rate for Payer: Anthem Medicare Advantage |
$121.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.15
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$1,408.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$741.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.15
|
| Rate for Payer: Health EOS Commercial |
$1,349.57
|
| Rate for Payer: HFN Commercial |
$1,408.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$427.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.15
|
| Rate for Payer: Multiplan Commercial |
$1,186.43
|
| Rate for Payer: NAPHCARE Commercial |
$181.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,408.89
|
| Rate for Payer: Quartz Beloit One Network |
$652.54
|
| Rate for Payer: Quartz Commercial |
$845.33
|
| Rate for Payer: Quartz Medicare Advantage |
$121.15
|
| Rate for Payer: The Alliance Commercial |
$478.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.15
|
| Rate for Payer: WEA Trust Commercial |
$815.67
|
| Rate for Payer: WPS Commercial |
$533.06
|
|
|
Tissue Culture, Non-Neo, Lympho
|
Facility
|
IP
|
$1,426.00
|
|
|
Service Code
|
CPT 88230
|
| Hospital Charge Code |
2778837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$726.69 |
| Max. Negotiated Rate |
$1,364.40 |
| Rate for Payer: Aetna Commercial |
$1,334.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,275.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$786.01
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$1,364.40
|
| Rate for Payer: Health EOS Commercial |
$1,319.91
|
| Rate for Payer: HFN Commercial |
$1,364.40
|
| Rate for Payer: Multiplan Commercial |
$1,186.43
|
| Rate for Payer: Preferred Network Access Commercial |
$1,364.40
|
| Rate for Payer: Quartz Beloit One Network |
$726.69
|
| Rate for Payer: Quartz Commercial |
$889.82
|
| Rate for Payer: WEA Trust Commercial |
$815.67
|
| Rate for Payer: WPS Commercial |
$1,098.45
|
|
|
Tissue Culture, Non-Neo, Lympho
|
Facility
|
OP
|
$1,426.00
|
|
|
Service Code
|
CPT 88230
|
| Hospital Charge Code |
2778837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.15 |
| Max. Negotiated Rate |
$1,364.40 |
| Rate for Payer: Aetna Commercial |
$1,334.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,275.41
|
| Rate for Payer: Aetna Managed Medicare |
$121.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$454.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$212.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$201.11
|
| Rate for Payer: Anthem Medicare Advantage |
$121.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$786.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.15
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Cigna Commercial |
$1,364.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$121.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$829.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$121.15
|
| Rate for Payer: Health EOS Commercial |
$1,319.91
|
| Rate for Payer: HFN Commercial |
$1,364.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$450.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$121.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$121.15
|
| Rate for Payer: Multiplan Commercial |
$1,186.43
|
| Rate for Payer: NAPHCARE Commercial |
$181.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,364.40
|
| Rate for Payer: Quartz Beloit One Network |
$726.69
|
| Rate for Payer: Quartz Commercial |
$963.98
|
| Rate for Payer: Quartz Medicare Advantage |
$121.15
|
| Rate for Payer: The Alliance Commercial |
$484.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.15
|
| Rate for Payer: United Healthcare PPO |
$1,112.28
|
| Rate for Payer: WEA Trust Commercial |
$815.67
|
| Rate for Payer: Wellcare Medicare |
$121.15
|
| Rate for Payer: WPS Commercial |
$1,098.45
|
|
|
Tissue Examination By KOH Slide Of Samples
|
Professional
|
Both
|
$94.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
1188852
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$92.87 |
| Rate for Payer: Aetna Commercial |
$92.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$92.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$48.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.44
|
| Rate for Payer: Health EOS Commercial |
$88.96
|
| Rate for Payer: HFN Commercial |
$92.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$92.87
|
| Rate for Payer: Quartz Beloit One Network |
$43.01
|
| Rate for Payer: Quartz Commercial |
$55.72
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$19.54
|
|
|
TISSUE EXPANDER 275CC 354211
|
Facility
|
OP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
2965394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,664.77 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,664.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,186.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,758.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,568.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,325.88
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,137.78
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: NAPHCARE Commercial |
$5,710.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$6,186.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,710.22
|
| Rate for Payer: The Alliance Commercial |
$4,240.29
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 275CC 354211
|
Facility
|
IP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
2965394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.35 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$5,710.22
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 400CC 133MV13
|
Facility
|
OP
|
$8,512.00
|
|
| Hospital Charge Code |
2964627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.69 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,754.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,426.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,249.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.98
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,639.36
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: NAPHCARE Commercial |
$5,311.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,754.11
|
| Rate for Payer: Quartz Medicare Advantage |
$5,311.49
|
| Rate for Payer: The Alliance Commercial |
$4,426.24
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER 400CC 133MV13
|
Facility
|
IP
|
$8,512.00
|
|
| Hospital Charge Code |
2964627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.72 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,311.49
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER 450CC 354213
|
Facility
|
IP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.35 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$5,710.22
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 450CC 354213
|
Facility
|
OP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,664.77 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,664.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,186.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,758.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,568.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,325.88
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,137.78
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: NAPHCARE Commercial |
$5,710.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$6,186.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,710.22
|
| Rate for Payer: The Alliance Commercial |
$4,758.52
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
