|
VisiPro 7mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
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 |
$128.93 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$157.87
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
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 |
$106.91 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Aetna Managed Medicare |
$106.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$171.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$126.30
|
| Rate for Payer: Anthem Medicare Advantage |
$106.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$106.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$106.91
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$106.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$106.91
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$397.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$106.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$106.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$106.91
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: NAPHCARE Commercial |
$160.37
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$171.03
|
| Rate for Payer: Quartz Medicare Advantage |
$106.91
|
| Rate for Payer: The Alliance Commercial |
$427.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.91
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: Wellcare Medicare |
$106.91
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.38 |
| Max. Negotiated Rate |
$92.26 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$22.38
|
| Rate for Payer: Anthem Medicare Advantage |
$22.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.38
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$50.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Health EOS Commercial |
$48.27
|
| Rate for Payer: HFN Commercial |
$50.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.38
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$33.57
|
| Rate for Payer: Preferred Network Access Commercial |
$50.39
|
| Rate for Payer: Quartz Beloit One Network |
$23.34
|
| Rate for Payer: Quartz Commercial |
$30.23
|
| Rate for Payer: Quartz Medicare Advantage |
$22.38
|
| Rate for Payer: The Alliance Commercial |
$61.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.38
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.17
|
|
|
VISI-WIPE 581047
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
VISI-WIPE 581047
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Vistaril 25 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$43.50 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.42
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Medicaid |
$13.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$36.06
|
|
|
Vistaril 25 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.08
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$63.27
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$36.06
|
|
|
Vistaril 25 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
VISUAL FIELD EXAMINATION(S) 92082
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 92082
|
| Hospital Charge Code |
3015325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.66 |
| Max. Negotiated Rate |
$189.49 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$47.37
|
| Rate for Payer: Anthem Medicare Advantage |
$47.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.37
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.37
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$167.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.37
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$71.06
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: Quartz Medicare Advantage |
$47.37
|
| Rate for Payer: The Alliance Commercial |
$118.43
|
| Rate for Payer: United Healthcare Medicaid |
$57.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.37
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
Visual Field Examination(s) 9208226
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 92082 26
|
| Hospital Charge Code |
4616612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$82.58 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$20.64
|
| Rate for Payer: Anthem Medicare Advantage |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.64
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.64
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.64
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$30.97
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: Quartz Medicare Advantage |
$20.64
|
| Rate for Payer: The Alliance Commercial |
$51.61
|
| Rate for Payer: United Healthcare Medicaid |
$22.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.64
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$82.58
|
|
|
Visual Field Examinations (S) 92083
|
Professional
|
Both
|
$432.00
|
|
|
Service Code
|
CPT 92083
|
| Hospital Charge Code |
3713512
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.13 |
| Max. Negotiated Rate |
$426.82 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.38
|
| Rate for Payer: Aetna Managed Medicare |
$63.82
|
| Rate for Payer: Anthem Medicare Advantage |
$63.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.82
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$426.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.82
|
| Rate for Payer: Health EOS Commercial |
$408.84
|
| Rate for Payer: HFN Commercial |
$426.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$224.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.82
|
| Rate for Payer: Multiplan Commercial |
$359.42
|
| Rate for Payer: NAPHCARE Commercial |
$95.74
|
| Rate for Payer: Preferred Network Access Commercial |
$426.82
|
| Rate for Payer: Quartz Beloit One Network |
$197.68
|
| Rate for Payer: Quartz Commercial |
$256.09
|
| Rate for Payer: Quartz Medicare Advantage |
$63.82
|
| Rate for Payer: The Alliance Commercial |
$159.56
|
| Rate for Payer: United Healthcare Medicaid |
$31.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.82
|
| Rate for Payer: WEA Trust Commercial |
$247.10
|
| Rate for Payer: WPS Commercial |
$255.30
|
|
|
Visual Field Exam (S) 9208326
|
Professional
|
Both
|
$432.00
|
|
|
Service Code
|
CPT 92083 26
|
| Hospital Charge Code |
3147511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.92 |
| Max. Negotiated Rate |
$426.82 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.38
|
| Rate for Payer: Aetna Managed Medicare |
$26.78
|
| Rate for Payer: Anthem Medicare Advantage |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.78
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$426.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.78
|
| Rate for Payer: Health EOS Commercial |
$408.84
|
| Rate for Payer: HFN Commercial |
$426.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$96.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.78
|
| Rate for Payer: Multiplan Commercial |
$359.42
|
| Rate for Payer: NAPHCARE Commercial |
$40.17
|
| Rate for Payer: Preferred Network Access Commercial |
$426.82
|
| Rate for Payer: Quartz Beloit One Network |
$197.68
|
| Rate for Payer: Quartz Commercial |
$256.09
|
| Rate for Payer: Quartz Medicare Advantage |
$26.78
|
| Rate for Payer: The Alliance Commercial |
$66.95
|
| Rate for Payer: United Healthcare Medicaid |
$19.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.78
|
| Rate for Payer: WEA Trust Commercial |
$247.10
|
| Rate for Payer: WPS Commercial |
$107.12
|
|
|
VISUAL FIELD XM UNI/BI W/INTERPRET LIMITED EXAM - 92081
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
CPT 92081
|
| Hospital Charge Code |
5785967
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna Commercial |
$151.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$33.58
|
| Rate for Payer: Anthem Medicare Advantage |
$33.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.58
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$151.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.58
|
| Rate for Payer: Health EOS Commercial |
$144.80
|
| Rate for Payer: HFN Commercial |
$151.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$118.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.58
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$50.37
|
| Rate for Payer: Preferred Network Access Commercial |
$151.16
|
| Rate for Payer: Quartz Beloit One Network |
$70.01
|
| Rate for Payer: Quartz Commercial |
$90.70
|
| Rate for Payer: Quartz Medicare Advantage |
$33.58
|
| Rate for Payer: The Alliance Commercial |
$83.95
|
| Rate for Payer: United Healthcare Medicaid |
$44.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.58
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$134.33
|
|
|
VISUALIZATION OF WINDPIPE 31615
|
Professional
|
Both
|
$1,397.00
|
|
|
Service Code
|
CPT 31615
|
| Hospital Charge Code |
3014397
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$98.47 |
| Max. Negotiated Rate |
$1,380.24 |
| Rate for Payer: Aetna Commercial |
$1,380.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,249.48
|
| Rate for Payer: Aetna Managed Medicare |
$98.47
|
| Rate for Payer: Anthem Medicare Advantage |
$98.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$98.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$98.47
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,380.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$164.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.47
|
| Rate for Payer: Health EOS Commercial |
$1,322.12
|
| Rate for Payer: HFN Commercial |
$1,380.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$394.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$98.47
|
| Rate for Payer: Multiplan Commercial |
$1,162.30
|
| Rate for Payer: NAPHCARE Commercial |
$147.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,380.24
|
| Rate for Payer: Quartz Beloit One Network |
$639.27
|
| Rate for Payer: Quartz Commercial |
$828.14
|
| Rate for Payer: Quartz Medicare Advantage |
$98.47
|
| Rate for Payer: The Alliance Commercial |
$418.49
|
| Rate for Payer: United Healthcare Medicaid |
$164.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$98.47
|
| Rate for Payer: WEA Trust Commercial |
$799.08
|
| Rate for Payer: WPS Commercial |
$443.10
|
|
|
VISUALIZATION SYSTEM CLEARIFY 21-345
|
Facility
|
OP
|
$646.00
|
|
| Hospital Charge Code |
4493782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.12 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$188.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$436.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$335.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$322.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.97
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.88
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$403.10
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$436.70
|
| Rate for Payer: Quartz Medicare Advantage |
$403.10
|
| Rate for Payer: The Alliance Commercial |
$335.92
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
VISUALIZATION SYSTEM CLEARIFY 21-345
|
Facility
|
IP
|
$646.00
|
|
| Hospital Charge Code |
4493782
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$329.20 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
