|
Voyager 2.75mm x 8mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 2.75mm x 8mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.0mm x 8mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.0mm x 8mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.0mm x 8mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.5mm x 8mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159054
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.5mm x 8mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159054
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 3.5mm x 8mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159054
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 4.0mm x 8 mm
|
Facility
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 4.0mm x 8 mm
|
Facility
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
Voyager 4.0mm x 8 mm
|
Professional
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.76 |
| Max. Negotiated Rate |
$1,808.80 |
| Rate for Payer: Aetna Commercial |
$1,808.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,808.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$952.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,142.40
|
| Rate for Payer: Health EOS Commercial |
$1,732.64
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,808.80
|
| Rate for Payer: Quartz Beloit One Network |
$837.76
|
| Rate for Payer: Quartz Commercial |
$1,085.28
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
VRE Screen
|
Professional
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$80.75 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$6.63
|
| Rate for Payer: Anthem Medicare Advantage |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.63
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.63
|
| Rate for Payer: Health EOS Commercial |
$77.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.63
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: Preferred Network Access Commercial |
$80.75
|
| Rate for Payer: Quartz Beloit One Network |
$37.40
|
| Rate for Payer: Quartz Commercial |
$48.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6.63
|
| Rate for Payer: The Alliance Commercial |
$26.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.63
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$29.17
|
|
|
VRE Screen
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
VRE Screen
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
979916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$6.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.01
|
| Rate for Payer: Anthem Medicaid |
$6.85
|
| Rate for Payer: Anthem Medicare Advantage |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.63
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.85
|
| Rate for Payer: Dean Health Medicaid |
$6.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.63
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.63
|
| Rate for Payer: Managed Health Services Medicaid |
$7.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.63
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$9.94
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.85
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$55.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6.63
|
| Rate for Payer: The Alliance Commercial |
$340.00
|
| Rate for Payer: United Healthcare Medicaid |
$6.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.63
|
| Rate for Payer: United Healthcare PPO |
$63.75
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: Wellcare Medicare |
$6.63
|
| Rate for Payer: WMAP Medicaid |
$6.85
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
VULVAPLASTY
|
Facility
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960507
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
VULVAPLASTY
|
Facility
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960507
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
OP
|
$11,495.25
|
|
|
Service Code
|
CPT 56620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$11,495.25 |
| Rate for Payer: Aetna Managed Medicare |
$3,090.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,090.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,090.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,090.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,339.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,090.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,495.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,090.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,090.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,090.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,090.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,635.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,090.12
|
| Rate for Payer: The Alliance Commercial |
$7,358.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,090.12
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,090.12
|
|
|
VZV, Rapid Cx / 2691
|
Facility
OP
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$1,532.00 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| 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 |
$202.99
|
| 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 |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| 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 |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| 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 |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$29.34
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.06
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$248.95
|
| Rate for Payer: Quartz Medicare Advantage |
$19.56
|
| Rate for Payer: The Alliance Commercial |
$1,532.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.56
|
| Rate for Payer: United Healthcare PPO |
$287.25
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: Wellcare Medicare |
$19.56
|
| Rate for Payer: WMAP Medicaid |
$7.06
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
VZV, Rapid Cx / 2691
|
Facility
IP
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.67 |
| Max. Negotiated Rate |
$352.36 |
| Rate for Payer: Aetna Commercial |
$344.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.99
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$352.36
|
| Rate for Payer: Health EOS Commercial |
$340.87
|
| Rate for Payer: HFN Commercial |
$352.36
|
| Rate for Payer: Multiplan Commercial |
$306.40
|
| Rate for Payer: NAPHCARE Commercial |
$229.80
|
| Rate for Payer: Preferred Network Access Commercial |
$352.36
|
| Rate for Payer: Quartz Beloit One Network |
$187.67
|
| Rate for Payer: Quartz Commercial |
$229.80
|
| Rate for Payer: WEA Trust Commercial |
$210.65
|
| Rate for Payer: WPS Commercial |
$283.69
|
|
|
VZV, Rapid Cx / 2691
|
Professional
|
$383.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
5773623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$363.85 |
| Rate for Payer: Aetna Commercial |
$363.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.38
|
| 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 |
$114.90
|
| Rate for Payer: Cash Price |
$114.90
|
| Rate for Payer: Cigna Commercial |
$363.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$191.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.56
|
| Rate for Payer: Health EOS Commercial |
$348.53
|
| 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 |
$306.40
|
| Rate for Payer: Preferred Network Access Commercial |
$363.85
|
| Rate for Payer: Quartz Beloit One Network |
$168.52
|
| Rate for Payer: Quartz Commercial |
$218.31
|
| 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 |
$210.65
|
| Rate for Payer: WPS Commercial |
$86.06
|
|
|
WA1 IgG Antibody, IFA
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
WA1 IgG Antibody, IFA
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$12.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.57
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.39
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.39
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.39
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.39
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.58
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$12.39
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.39
|
| Rate for Payer: United Healthcare PPO |
$113.25
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: Wellcare Medicare |
$12.39
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
WA1 IgG Antibody, IFA
|
Professional
|
$151.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
5355236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.39 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna Commercial |
$143.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$12.39
|
| Rate for Payer: Anthem Medicare Advantage |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.39
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$143.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.39
|
| Rate for Payer: Health EOS Commercial |
$137.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.39
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.45
|
| Rate for Payer: Quartz Beloit One Network |
$66.44
|
| Rate for Payer: Quartz Commercial |
$86.07
|
| Rate for Payer: Quartz Medicare Advantage |
$12.39
|
| Rate for Payer: The Alliance Commercial |
$48.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.39
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$54.52
|
|
|
WAIS IV RECORD FORM
|
Facility
IP
|
$1,754.00
|
|
| Hospital Charge Code |
2972682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$859.46 |
| Max. Negotiated Rate |
$1,613.68 |
| Rate for Payer: Aetna Commercial |
$1,578.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.62
|
| Rate for Payer: Cash Price |
$526.20
|
| Rate for Payer: Cigna Commercial |
$1,613.68
|
| Rate for Payer: Health EOS Commercial |
$1,561.06
|
| Rate for Payer: HFN Commercial |
$1,613.68
|
| Rate for Payer: Multiplan Commercial |
$1,403.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,052.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,613.68
|
| Rate for Payer: Quartz Beloit One Network |
$859.46
|
| Rate for Payer: Quartz Commercial |
$1,052.40
|
| Rate for Payer: WEA Trust Commercial |
$964.70
|
| Rate for Payer: WPS Commercial |
$1,299.19
|
|
|
WAIS IV RECORD FORM
|
Facility
OP
|
$1,754.00
|
|
| Hospital Charge Code |
2972682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$491.12 |
| Max. Negotiated Rate |
$7,016.00 |
| Rate for Payer: Aetna Commercial |
$1,578.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,508.44
|
| Rate for Payer: Aetna Managed Medicare |
$491.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,140.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$877.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$841.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$929.62
|
| Rate for Payer: Cash Price |
$526.20
|
| Rate for Payer: Cigna Commercial |
$1,613.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$981.54
|
| Rate for Payer: Health EOS Commercial |
$1,561.06
|
| Rate for Payer: HFN Commercial |
$1,613.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,315.50
|
| Rate for Payer: Multiplan Commercial |
$1,403.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,052.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,613.68
|
| Rate for Payer: Quartz Beloit One Network |
$859.46
|
| Rate for Payer: Quartz Commercial |
$1,140.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,052.40
|
| Rate for Payer: The Alliance Commercial |
$7,016.00
|
| Rate for Payer: WEA Trust Commercial |
$964.70
|
| Rate for Payer: WPS Commercial |
$1,299.19
|
|
