|
.Viral ID Resp PCR
|
Professional
|
$170.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
6182672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Aetna Commercial |
$161.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.56
|
| Rate for Payer: Anthem Medicare Advantage |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.56
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.56
|
| Rate for Payer: Health EOS Commercial |
$154.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.56
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.50
|
| Rate for Payer: Quartz Beloit One Network |
$74.80
|
| Rate for Payer: Quartz Commercial |
$96.90
|
| Rate for Payer: Quartz Medicare Advantage |
$19.56
|
| Rate for Payer: The Alliance Commercial |
$77.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$86.06
|
|
|
.Viral ID Resp PCR
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
6182672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.47
|
| Rate for Payer: Anthem Medicaid |
$7.06
|
| Rate for Payer: Anthem Medicare Advantage |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.56
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.06
|
| Rate for Payer: Dean Health Medicaid |
$7.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.56
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.56
|
| Rate for Payer: Managed Health Services Medicaid |
$7.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.56
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$29.34
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.06
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$19.56
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: United Healthcare PPO |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: Wellcare Medicare |
$19.56
|
| Rate for Payer: WMAP Medicaid |
$7.06
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
VIRAL ILLNESS WITH MCC
|
Facility
IP
|
$43,919.00
|
|
|
Service Code
|
MS-DRG 865
|
| Min. Negotiated Rate |
$15,798.11 |
| Max. Negotiated Rate |
$43,919.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,798.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,407.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,372.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,055.92
|
| Rate for Payer: Anthem Medicare Advantage |
$15,798.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,798.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,798.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,798.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,814.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,798.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,978.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,798.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,798.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,798.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,798.11
|
| Rate for Payer: NAPHCARE Commercial |
$23,697.16
|
| Rate for Payer: Quartz Medicare Advantage |
$15,798.11
|
| Rate for Payer: The Alliance Commercial |
$43,919.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,798.11
|
| Rate for Payer: United Healthcare PPO |
$24,895.32
|
| Rate for Payer: Wellcare Medicare |
$15,798.11
|
|
|
VIRAL ILLNESS WITHOUT MCC
|
Facility
IP
|
$24,718.00
|
|
|
Service Code
|
MS-DRG 866
|
| Min. Negotiated Rate |
$8,891.49 |
| Max. Negotiated Rate |
$24,718.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,891.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,301.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,794.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,055.76
|
| Rate for Payer: Anthem Medicare Advantage |
$8,891.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,891.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,891.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,891.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,603.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,891.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,895.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,891.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,891.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,891.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,891.49
|
| Rate for Payer: NAPHCARE Commercial |
$13,337.24
|
| Rate for Payer: Quartz Medicare Advantage |
$8,891.49
|
| Rate for Payer: The Alliance Commercial |
$24,718.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,891.49
|
| Rate for Payer: United Healthcare PPO |
$13,931.60
|
| Rate for Payer: Wellcare Medicare |
$8,891.49
|
|
|
VIRAL MENINGITIS WITH CC/MCC
|
Facility
IP
|
$51,201.00
|
|
|
Service Code
|
MS-DRG 075
|
| Min. Negotiated Rate |
$18,417.50 |
| Max. Negotiated Rate |
$51,201.00 |
| Rate for Payer: Aetna Managed Medicare |
$18,417.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40,071.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30,714.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29,180.98
|
| Rate for Payer: Anthem Medicare Advantage |
$18,417.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18,417.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18,417.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18,417.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32,393.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18,417.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37,319.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18,417.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18,417.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18,417.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18,417.50
|
| Rate for Payer: NAPHCARE Commercial |
$27,626.25
|
| Rate for Payer: Quartz Medicare Advantage |
$18,417.50
|
| Rate for Payer: The Alliance Commercial |
$51,201.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18,417.50
|
| Rate for Payer: United Healthcare PPO |
$29,053.40
|
| Rate for Payer: Wellcare Medicare |
$18,417.50
|
|
|
VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
IP
|
$24,846.00
|
|
|
Service Code
|
MS-DRG 076
|
| Min. Negotiated Rate |
$8,937.40 |
| Max. Negotiated Rate |
$24,846.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,937.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,301.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,794.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,055.76
|
| Rate for Payer: Anthem Medicare Advantage |
$8,937.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,937.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,937.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,937.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,603.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,937.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,988.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,937.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,937.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,937.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,937.40
|
| Rate for Payer: NAPHCARE Commercial |
$13,406.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8,937.40
|
| Rate for Payer: The Alliance Commercial |
$24,846.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,937.40
|
| Rate for Payer: United Healthcare PPO |
$14,004.47
|
| Rate for Payer: Wellcare Medicare |
$8,937.40
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Professional
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$19.56
|
| Rate for Payer: Anthem Medicare Advantage |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.56
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$342.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$180.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.56
|
| Rate for Payer: Health EOS Commercial |
$327.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.56
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$342.00
|
| Rate for Payer: Quartz Beloit One Network |
$158.40
|
| Rate for Payer: Quartz Commercial |
$205.20
|
| Rate for Payer: Quartz Medicare Advantage |
$19.56
|
| Rate for Payer: The Alliance Commercial |
$77.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$86.06
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Facility
OP
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$19.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.47
|
| Rate for Payer: Anthem Medicaid |
$7.06
|
| Rate for Payer: Anthem Medicare Advantage |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.56
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.06
|
| Rate for Payer: Dean Health Medicaid |
$7.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.56
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.56
|
| Rate for Payer: Managed Health Services Medicaid |
$7.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.56
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$29.34
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.06
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: Quartz Medicare Advantage |
$19.56
|
| Rate for Payer: The Alliance Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: United Healthcare PPO |
$270.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: Wellcare Medicare |
$19.56
|
| Rate for Payer: WMAP Medicaid |
$7.06
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Facility
IP
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
VIRTUOSAPH PLUS EVH SYSTEM VSP550EX
|
Facility
IP
|
$9,974.00
|
|
| Hospital Charge Code |
2967354
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,887.26 |
| Max. Negotiated Rate |
$9,176.08 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$5,984.40
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$7,387.74
|
|
|
VIRTUOSAPH PLUS EVH SYSTEM VSP550EX
|
Facility
OP
|
$9,974.00
|
|
| Hospital Charge Code |
2967354
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,792.72 |
| Max. Negotiated Rate |
$39,896.00 |
| Rate for Payer: Aetna Commercial |
$8,976.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,577.64
|
| Rate for Payer: Aetna Managed Medicare |
$2,792.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,483.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,987.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,787.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,286.22
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,176.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,581.45
|
| Rate for Payer: Health EOS Commercial |
$8,876.86
|
| Rate for Payer: HFN Commercial |
$9,176.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,480.50
|
| Rate for Payer: Multiplan Commercial |
$7,979.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,984.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,176.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,887.26
|
| Rate for Payer: Quartz Commercial |
$6,483.10
|
| Rate for Payer: Quartz Medicare Advantage |
$5,984.40
|
| Rate for Payer: The Alliance Commercial |
$39,896.00
|
| Rate for Payer: WEA Trust Commercial |
$5,485.70
|
| Rate for Payer: WPS Commercial |
$7,387.74
|
|
|
Viscosity Serum Level
|
Professional
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Aetna Commercial |
$286.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.72
|
| Rate for Payer: Aetna Managed Medicare |
$11.67
|
| Rate for Payer: Anthem Medicare Advantage |
$11.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.67
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$286.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$151.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.67
|
| Rate for Payer: Health EOS Commercial |
$274.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.67
|
| Rate for Payer: Multiplan Commercial |
$241.60
|
| Rate for Payer: Preferred Network Access Commercial |
$286.90
|
| Rate for Payer: Quartz Beloit One Network |
$132.88
|
| Rate for Payer: Quartz Commercial |
$172.14
|
| Rate for Payer: Quartz Medicare Advantage |
$11.67
|
| Rate for Payer: The Alliance Commercial |
$46.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.67
|
| Rate for Payer: WEA Trust Commercial |
$166.10
|
| Rate for Payer: WPS Commercial |
$51.35
|
|
|
Viscosity Serum Level
|
Facility
OP
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$1,208.00 |
| Rate for Payer: Aetna Commercial |
$271.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.72
|
| Rate for Payer: Aetna Managed Medicare |
$11.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.37
|
| Rate for Payer: Anthem Medicaid |
$12.06
|
| Rate for Payer: Anthem Medicare Advantage |
$11.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.67
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$277.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.06
|
| Rate for Payer: Dean Health Medicaid |
$12.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.67
|
| Rate for Payer: Health EOS Commercial |
$268.78
|
| Rate for Payer: HFN Commercial |
$277.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.67
|
| Rate for Payer: Managed Health Services Medicaid |
$12.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.67
|
| Rate for Payer: Multiplan Commercial |
$241.60
|
| Rate for Payer: NAPHCARE Commercial |
$17.50
|
| Rate for Payer: Preferred Network Access Commercial |
$277.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.06
|
| Rate for Payer: Quartz Beloit One Network |
$147.98
|
| Rate for Payer: Quartz Commercial |
$196.30
|
| Rate for Payer: Quartz Medicare Advantage |
$11.67
|
| Rate for Payer: The Alliance Commercial |
$1,208.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.67
|
| Rate for Payer: United Healthcare PPO |
$226.50
|
| Rate for Payer: WEA Trust Commercial |
$166.10
|
| Rate for Payer: Wellcare Medicare |
$11.67
|
| Rate for Payer: WMAP Medicaid |
$12.06
|
| Rate for Payer: WPS Commercial |
$223.69
|
|
|
Viscosity Serum Level
|
Facility
IP
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.98 |
| Max. Negotiated Rate |
$277.84 |
| Rate for Payer: Aetna Commercial |
$271.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.06
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$277.84
|
| Rate for Payer: Health EOS Commercial |
$268.78
|
| Rate for Payer: HFN Commercial |
$277.84
|
| Rate for Payer: Multiplan Commercial |
$241.60
|
| Rate for Payer: NAPHCARE Commercial |
$181.20
|
| Rate for Payer: Preferred Network Access Commercial |
$277.84
|
| Rate for Payer: Quartz Beloit One Network |
$147.98
|
| Rate for Payer: Quartz Commercial |
$181.20
|
| Rate for Payer: WEA Trust Commercial |
$166.10
|
| Rate for Payer: WPS Commercial |
$223.69
|
|
|
Vision 2.5mm x 23mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 2.5mm x 23mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 2.5mm x 23mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 12mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 12mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 12mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 18mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 18mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 18mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 23mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 23mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
