|
VisiPro 7mm x 17mm
|
Professional
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 17mm
|
Facility
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 17mm
|
Facility
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Facility
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Facility
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Professional
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Professional
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Facility
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Facility
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Facility
IP
|
$253.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$123.97 |
| Max. Negotiated Rate |
$232.76 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$151.80
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$151.80
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Facility
OP
|
$253.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.10 |
| Max. Negotiated Rate |
$346.32 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Aetna Managed Medicare |
$88.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.44
|
| Rate for Payer: Anthem Medicare Advantage |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.10
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$88.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$88.10
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$88.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$88.10
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$132.15
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$164.45
|
| Rate for Payer: Quartz Medicare Advantage |
$88.10
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.10
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: Wellcare Medicare |
$88.10
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Professional
|
$51.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$88.71 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$24.49
|
| Rate for Payer: Anthem Medicare Advantage |
$24.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.49
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.49
|
| Rate for Payer: Health EOS Commercial |
$46.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.49
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.45
|
| Rate for Payer: Quartz Beloit One Network |
$22.44
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: Quartz Medicare Advantage |
$24.49
|
| Rate for Payer: The Alliance Commercial |
$67.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.49
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$42.86
|
|
|
VISI-WIPE 581047
|
Facility
OP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
VISI-WIPE 581047
|
Facility
IP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Vistaril 25 mg Charge
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Vistaril 25 mg Charge
|
Professional
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$37.46 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$13.62
|
| Rate for Payer: Anthem Medicare Advantage |
$13.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.62
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.87
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.62
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: Quartz Medicare Advantage |
$13.62
|
| Rate for Payer: The Alliance Commercial |
$37.46
|
| Rate for Payer: United Healthcare Medicaid |
$13.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.62
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$34.67
|
|
|
Vistaril 25 mg Charge
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$1,196.24 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.35
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$34.67
|
|
|
VISUAL FIELD EXAMINATION(S) 92082
|
Professional
|
$67.00
|
|
|
Service Code
|
CPT 92082
|
| Hospital Charge Code |
3015325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$179.96 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$44.99
|
| Rate for Payer: Anthem Medicare Advantage |
$44.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$44.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$44.99
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.99
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$161.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: Quartz Medicare Advantage |
$44.99
|
| Rate for Payer: The Alliance Commercial |
$112.48
|
| Rate for Payer: United Healthcare Medicaid |
$54.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44.99
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$179.96
|
|
|
Visual Field Examination(s) 9208226
|
Professional
|
$67.00
|
|
|
Service Code
|
CPT 92082 26
|
| Hospital Charge Code |
4616612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$80.40 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$20.10
|
| Rate for Payer: Anthem Medicare Advantage |
$20.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.10
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.10
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: Quartz Medicare Advantage |
$20.10
|
| Rate for Payer: The Alliance Commercial |
$50.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.10
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$80.40
|
|
|
Visual Field Examinations (S) 92083
|
Professional
|
$432.00
|
|
|
Service Code
|
CPT 92083
|
| Hospital Charge Code |
3713512
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.93 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.52
|
| Rate for Payer: Aetna Managed Medicare |
$60.29
|
| Rate for Payer: Anthem Medicare Advantage |
$60.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$60.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$60.29
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$410.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$216.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.29
|
| Rate for Payer: Health EOS Commercial |
$393.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$215.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$215.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$60.29
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$410.40
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$246.24
|
| Rate for Payer: Quartz Medicare Advantage |
$60.29
|
| Rate for Payer: The Alliance Commercial |
$150.72
|
| Rate for Payer: United Healthcare Medicaid |
$29.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.29
|
| Rate for Payer: WEA Trust Commercial |
$237.60
|
| Rate for Payer: WPS Commercial |
$241.16
|
|
|
Visual Field Exam (S) 9208326
|
Professional
|
$432.00
|
|
|
Service Code
|
CPT 92083 26
|
| Hospital Charge Code |
3147511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.06 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.52
|
| Rate for Payer: Aetna Managed Medicare |
$26.06
|
| Rate for Payer: Anthem Medicare Advantage |
$26.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.06
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$410.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$216.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.06
|
| Rate for Payer: Health EOS Commercial |
$393.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$93.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.06
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: Preferred Network Access Commercial |
$410.40
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$246.24
|
| Rate for Payer: Quartz Medicare Advantage |
$26.06
|
| Rate for Payer: The Alliance Commercial |
$65.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.06
|
| Rate for Payer: WEA Trust Commercial |
$237.60
|
| Rate for Payer: WPS Commercial |
$104.24
|
|
|
VISUAL FIELD XM UNI/BI W/INTERPRET LIMITED EXAM - 92081
|
Professional
|
$153.00
|
|
|
Service Code
|
CPT 92081
|
| Hospital Charge Code |
5785967
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.95 |
| Max. Negotiated Rate |
$145.35 |
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$31.95
|
| Rate for Payer: Anthem Medicare Advantage |
$31.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.95
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$145.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$76.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.95
|
| Rate for Payer: Health EOS Commercial |
$139.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$114.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.95
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: Preferred Network Access Commercial |
$145.35
|
| Rate for Payer: Quartz Beloit One Network |
$67.32
|
| Rate for Payer: Quartz Commercial |
$87.21
|
| Rate for Payer: Quartz Medicare Advantage |
$31.95
|
| Rate for Payer: The Alliance Commercial |
$79.88
|
| Rate for Payer: United Healthcare Medicaid |
$42.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.95
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$127.80
|
|
|
VISUALIZATION OF WINDPIPE 31615
|
Professional
|
$1,397.00
|
|
|
Service Code
|
CPT 31615
|
| Hospital Charge Code |
3014397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$107.83 |
| Max. Negotiated Rate |
$1,327.15 |
| Rate for Payer: Aetna Commercial |
$1,327.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Aetna Managed Medicare |
$107.83
|
| Rate for Payer: Anthem Medicare Advantage |
$107.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$107.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$107.83
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,327.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$698.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.83
|
| Rate for Payer: Health EOS Commercial |
$1,271.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$379.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$107.83
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,327.15
|
| Rate for Payer: Quartz Beloit One Network |
$614.68
|
| Rate for Payer: Quartz Commercial |
$796.29
|
| Rate for Payer: Quartz Medicare Advantage |
$107.83
|
| Rate for Payer: The Alliance Commercial |
$458.28
|
| Rate for Payer: United Healthcare Medicaid |
$158.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.83
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$485.24
|
|
|
VISUALIZATION SYSTEM CLEARIFY 21-345
|
Facility
IP
|
$646.00
|
|
| Hospital Charge Code |
4493782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.54 |
| Max. Negotiated Rate |
$594.32 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$387.60
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
|
VISUALIZATION SYSTEM CLEARIFY 21-345
|
Facility
OP
|
$646.00
|
|
| Hospital Charge Code |
4493782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.88 |
| Max. Negotiated Rate |
$2,584.00 |
| Rate for Payer: Aetna Commercial |
$581.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.56
|
| Rate for Payer: Aetna Managed Medicare |
$180.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$323.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.38
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$594.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$361.50
|
| Rate for Payer: Health EOS Commercial |
$574.94
|
| Rate for Payer: HFN Commercial |
$594.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$484.50
|
| Rate for Payer: Multiplan Commercial |
$516.80
|
| Rate for Payer: NAPHCARE Commercial |
$387.60
|
| Rate for Payer: Preferred Network Access Commercial |
$594.32
|
| Rate for Payer: Quartz Beloit One Network |
$316.54
|
| Rate for Payer: Quartz Commercial |
$419.90
|
| Rate for Payer: Quartz Medicare Advantage |
$387.60
|
| Rate for Payer: The Alliance Commercial |
$2,584.00
|
| Rate for Payer: WEA Trust Commercial |
$355.30
|
| Rate for Payer: WPS Commercial |
$478.49
|
|
