|
DERMABRASION SEGMENTAL FACE 15781
|
Professional
|
Both
|
$973.00
|
|
|
Service Code
|
CPT 15781
|
| Hospital Charge Code |
6113632
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$428.12 |
| Max. Negotiated Rate |
$1,430.74 |
| Rate for Payer: Aetna Commercial |
$924.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.78
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cash Price |
$291.90
|
| Rate for Payer: Cigna Commercial |
$924.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$736.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$583.80
|
| Rate for Payer: Health EOS Commercial |
$885.43
|
| Rate for Payer: HFN Commercial |
$924.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,430.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,430.74
|
| Rate for Payer: Multiplan Commercial |
$778.40
|
| Rate for Payer: Preferred Network Access Commercial |
$924.35
|
| Rate for Payer: Quartz Beloit One Network |
$428.12
|
| Rate for Payer: Quartz Commercial |
$554.61
|
| Rate for Payer: The Alliance Commercial |
$486.50
|
| Rate for Payer: United Healthcare Medicaid |
$736.48
|
| Rate for Payer: WEA Trust Commercial |
$535.15
|
| Rate for Payer: WPS Commercial |
$720.70
|
|
|
DERMACARRIER 8 STERILE 00-7708-000-10
|
Facility
|
OP
|
$657.00
|
|
| Hospital Charge Code |
2967417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.96 |
| Max. Negotiated Rate |
$2,628.00 |
| Rate for Payer: Aetna Commercial |
$591.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$565.02
|
| Rate for Payer: Aetna Managed Medicare |
$183.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$427.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$328.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$315.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$348.21
|
| Rate for Payer: Cash Price |
$197.10
|
| Rate for Payer: Cigna Commercial |
$604.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$367.66
|
| Rate for Payer: Health EOS Commercial |
$584.73
|
| Rate for Payer: HFN Commercial |
$604.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$492.75
|
| Rate for Payer: Multiplan Commercial |
$525.60
|
| Rate for Payer: NAPHCARE Commercial |
$394.20
|
| Rate for Payer: Preferred Network Access Commercial |
$604.44
|
| Rate for Payer: Quartz Beloit One Network |
$321.93
|
| Rate for Payer: Quartz Commercial |
$427.05
|
| Rate for Payer: Quartz Medicare Advantage |
$394.20
|
| Rate for Payer: The Alliance Commercial |
$2,628.00
|
| Rate for Payer: WEA Trust Commercial |
$361.35
|
| Rate for Payer: WPS Commercial |
$486.64
|
|
|
DERMACARRIER 8 STERILE 00-7708-000-10
|
Facility
|
IP
|
$657.00
|
|
| Hospital Charge Code |
2967417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$321.93 |
| Max. Negotiated Rate |
$604.44 |
| Rate for Payer: Aetna Commercial |
$591.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$565.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$348.21
|
| Rate for Payer: Cash Price |
$197.10
|
| Rate for Payer: Cigna Commercial |
$604.44
|
| Rate for Payer: Health EOS Commercial |
$584.73
|
| Rate for Payer: HFN Commercial |
$604.44
|
| Rate for Payer: Multiplan Commercial |
$525.60
|
| Rate for Payer: NAPHCARE Commercial |
$394.20
|
| Rate for Payer: Preferred Network Access Commercial |
$604.44
|
| Rate for Payer: Quartz Beloit One Network |
$321.93
|
| Rate for Payer: Quartz Commercial |
$394.20
|
| Rate for Payer: WEA Trust Commercial |
$361.35
|
| Rate for Payer: WPS Commercial |
$486.64
|
|
|
Dermagraft per sq cm Q4106
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.80
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: HFN Commercial |
$116.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$111.97
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: The Alliance Commercial |
$61.50
|
| Rate for Payer: United Healthcare Medicaid |
$35.42
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Dermagraft per sq cm Q4106
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Dermagraft per sq cm Q4106
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
3133667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Dermatopathology Consult
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
3781385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.43 |
| Max. Negotiated Rate |
$190.44 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$124.20
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$124.20
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Dermatopathology Consult
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
3781385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.08 |
| Max. Negotiated Rate |
$334.01 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$196.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$188.37
|
| Rate for Payer: HFN Commercial |
$196.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$334.01
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$196.65
|
| Rate for Payer: Quartz Beloit One Network |
$91.08
|
| Rate for Payer: Quartz Commercial |
$117.99
|
| Rate for Payer: The Alliance Commercial |
$103.50
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Dermatopathology Consult
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 88321
|
| Hospital Charge Code |
3781385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$190.44 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.80
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$134.55
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: The Alliance Commercial |
$158.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$155.25
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Dermatophyte Screen
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
979919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$7.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.80
|
| Rate for Payer: Anthem Medicaid |
$7.97
|
| Rate for Payer: Anthem Medicare Advantage |
$7.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.71
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Dean Health Medicaid |
$7.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.71
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.71
|
| Rate for Payer: Managed Health Services Medicaid |
$8.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.71
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$11.56
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.97
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$7.71
|
| Rate for Payer: The Alliance Commercial |
$30.84
|
| Rate for Payer: United Healthcare Medicaid |
$7.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.71
|
| Rate for Payer: United Healthcare PPO |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: Wellcare Medicare |
$7.71
|
| Rate for Payer: WMAP Medicaid |
$7.97
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Dermatophyte Screen
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
979919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Dermatophyte Screen
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
979919
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$150.10 |
| Rate for Payer: Aetna Commercial |
$150.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$150.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.80
|
| Rate for Payer: Health EOS Commercial |
$143.78
|
| Rate for Payer: HFN Commercial |
$150.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.22
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.10
|
| Rate for Payer: Quartz Beloit One Network |
$69.52
|
| Rate for Payer: Quartz Commercial |
$90.06
|
| Rate for Payer: The Alliance Commercial |
$79.00
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
DERM AUTOGRAFT, TRNK/ARM/LEG 15130
|
Professional
|
Both
|
$3,149.00
|
|
|
Service Code
|
CPT 15130
|
| Hospital Charge Code |
3013638
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$553.95 |
| Max. Negotiated Rate |
$2,991.55 |
| Rate for Payer: Aetna Commercial |
$2,991.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,708.14
|
| Rate for Payer: Cash Price |
$944.70
|
| Rate for Payer: Cash Price |
$944.70
|
| Rate for Payer: Cigna Commercial |
$2,991.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$553.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,889.40
|
| Rate for Payer: Health EOS Commercial |
$2,865.59
|
| Rate for Payer: HFN Commercial |
$2,991.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,974.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,974.19
|
| Rate for Payer: Multiplan Commercial |
$2,519.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,991.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,385.56
|
| Rate for Payer: Quartz Commercial |
$1,794.93
|
| Rate for Payer: The Alliance Commercial |
$1,574.50
|
| Rate for Payer: United Healthcare Medicaid |
$553.95
|
| Rate for Payer: WEA Trust Commercial |
$1,731.95
|
| Rate for Payer: WPS Commercial |
$2,332.46
|
|
|
DermPath Level IV
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
3279479
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.76 |
| Max. Negotiated Rate |
$206.08 |
| Rate for Payer: Aetna Commercial |
$201.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.72
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$206.08
|
| Rate for Payer: Health EOS Commercial |
$199.36
|
| Rate for Payer: HFN Commercial |
$206.08
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$206.08
|
| Rate for Payer: Quartz Beloit One Network |
$109.76
|
| Rate for Payer: Quartz Commercial |
$134.40
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
DermPath Level IV
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
3279479
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.69 |
| Max. Negotiated Rate |
$241.63 |
| Rate for Payer: Aetna Commercial |
$212.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Anthem Commercial |
$34.69
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$212.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.40
|
| Rate for Payer: Health EOS Commercial |
$203.84
|
| Rate for Payer: HFN Commercial |
$212.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$241.63
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: Preferred Network Access Commercial |
$212.80
|
| Rate for Payer: Quartz Beloit One Network |
$98.56
|
| Rate for Payer: Quartz Commercial |
$127.68
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
DermPath Level IV
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
3279479
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.56 |
| Max. Negotiated Rate |
$214.24 |
| Rate for Payer: Aetna Commercial |
$201.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Aetna Managed Medicare |
$53.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.91
|
| Rate for Payer: Anthem Medicare Advantage |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.56
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$206.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.56
|
| Rate for Payer: Health EOS Commercial |
$199.36
|
| Rate for Payer: HFN Commercial |
$206.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.56
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.34
|
| Rate for Payer: Preferred Network Access Commercial |
$206.08
|
| Rate for Payer: Quartz Beloit One Network |
$109.76
|
| Rate for Payer: Quartz Commercial |
$145.60
|
| Rate for Payer: Quartz Medicare Advantage |
$53.56
|
| Rate for Payer: The Alliance Commercial |
$214.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.56
|
| Rate for Payer: United Healthcare PPO |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: Wellcare Medicare |
$53.56
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
Desipramine Level
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$455.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.40
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| Rate for Payer: HFN Commercial |
$455.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$455.05
|
| Rate for Payer: Quartz Beloit One Network |
$210.76
|
| Rate for Payer: Quartz Commercial |
$273.03
|
| Rate for Payer: The Alliance Commercial |
$239.50
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Desipramine Level
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$287.40
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Desipramine Level
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
977922
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$1,916.00 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$134.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.05
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$359.25
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$311.35
|
| Rate for Payer: Quartz Medicare Advantage |
$287.40
|
| Rate for Payer: The Alliance Commercial |
$1,916.00
|
| Rate for Payer: United Healthcare PPO |
$359.25
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
Destr of local les choroid, photocoag, 1 or more session 67220
|
Professional
|
Both
|
$1,302.00
|
|
|
Service Code
|
CPT 67220
|
| Hospital Charge Code |
5551405
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$572.88 |
| Max. Negotiated Rate |
$1,675.37 |
| Rate for Payer: Aetna Commercial |
$1,236.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,119.72
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cigna Commercial |
$1,236.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$630.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.20
|
| Rate for Payer: Health EOS Commercial |
$1,184.82
|
| Rate for Payer: HFN Commercial |
$1,236.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,675.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,675.37
|
| Rate for Payer: Multiplan Commercial |
$1,041.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,236.90
|
| Rate for Payer: Quartz Beloit One Network |
$572.88
|
| Rate for Payer: Quartz Commercial |
$742.14
|
| Rate for Payer: The Alliance Commercial |
$651.00
|
| Rate for Payer: United Healthcare Medicaid |
$630.68
|
| Rate for Payer: WEA Trust Commercial |
$716.10
|
| Rate for Payer: WPS Commercial |
$964.39
|
|
|
Destr of local les choroid, photocoag, 1 or more session 6722050
|
Professional
|
Both
|
$2,604.00
|
|
|
Service Code
|
CPT 67220 50
|
| Hospital Charge Code |
5551406
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,145.76 |
| Max. Negotiated Rate |
$2,473.80 |
| Rate for Payer: Aetna Commercial |
$2,473.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,239.44
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cigna Commercial |
$2,473.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,302.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,562.40
|
| Rate for Payer: Health EOS Commercial |
$2,369.64
|
| Rate for Payer: HFN Commercial |
$2,473.80
|
| Rate for Payer: Multiplan Commercial |
$2,083.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,473.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,145.76
|
| Rate for Payer: Quartz Commercial |
$1,484.28
|
| Rate for Payer: The Alliance Commercial |
$1,302.00
|
| Rate for Payer: WEA Trust Commercial |
$1,432.20
|
| Rate for Payer: WPS Commercial |
$1,928.78
|
|
|
Destroy Cervical/Thor Facet JT 64633
|
Professional
|
Both
|
$1,292.00
|
|
|
Service Code
|
CPT 64633
|
| Hospital Charge Code |
5232714
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$345.90 |
| Max. Negotiated Rate |
$1,227.40 |
| Rate for Payer: Aetna Commercial |
$1,227.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,111.12
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cash Price |
$387.60
|
| Rate for Payer: Cigna Commercial |
$1,227.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$345.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$775.20
|
| Rate for Payer: Health EOS Commercial |
$1,175.72
|
| Rate for Payer: HFN Commercial |
$1,227.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$759.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$759.13
|
| Rate for Payer: Multiplan Commercial |
$1,033.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,227.40
|
| Rate for Payer: Quartz Beloit One Network |
$568.48
|
| Rate for Payer: Quartz Commercial |
$736.44
|
| Rate for Payer: The Alliance Commercial |
$646.00
|
| Rate for Payer: United Healthcare Medicaid |
$345.90
|
| Rate for Payer: WEA Trust Commercial |
$710.60
|
| Rate for Payer: WPS Commercial |
$956.98
|
|
|
Destroy C/TH Facet Joint Addl 64634
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
CPT 64634
|
| Hospital Charge Code |
5232727
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$158.65 |
| Max. Negotiated Rate |
$380.95 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.86
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$380.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$158.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.60
|
| Rate for Payer: Health EOS Commercial |
$364.91
|
| Rate for Payer: HFN Commercial |
$380.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$228.81
|
| Rate for Payer: Multiplan Commercial |
$320.80
|
| Rate for Payer: Preferred Network Access Commercial |
$380.95
|
| Rate for Payer: Quartz Beloit One Network |
$176.44
|
| Rate for Payer: Quartz Commercial |
$228.57
|
| Rate for Payer: The Alliance Commercial |
$200.50
|
| Rate for Payer: United Healthcare Medicaid |
$158.65
|
| Rate for Payer: WEA Trust Commercial |
$220.55
|
| Rate for Payer: WPS Commercial |
$297.02
|
|
|
Destroy L/S Facet Joint Add Level 64636
|
Professional
|
Both
|
$494.00
|
|
|
Service Code
|
CPT 64636
|
| Hospital Charge Code |
5232731
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.84 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Aetna Commercial |
$469.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$424.84
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$469.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.40
|
| Rate for Payer: Health EOS Commercial |
$449.54
|
| Rate for Payer: HFN Commercial |
$469.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$201.42
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: Preferred Network Access Commercial |
$469.30
|
| Rate for Payer: Quartz Beloit One Network |
$217.36
|
| Rate for Payer: Quartz Commercial |
$281.58
|
| Rate for Payer: The Alliance Commercial |
$247.00
|
| Rate for Payer: United Healthcare Medicaid |
$142.84
|
| Rate for Payer: WEA Trust Commercial |
$271.70
|
| Rate for Payer: WPS Commercial |
$365.91
|
|
|
Destroy L/S Facet Joint Add Level 6463650
|
Professional
|
Both
|
$3,685.00
|
|
|
Service Code
|
CPT 64636 50
|
| Hospital Charge Code |
5232732
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$142.84 |
| Max. Negotiated Rate |
$3,500.75 |
| Rate for Payer: Aetna Commercial |
$3,500.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,169.10
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cash Price |
$1,105.50
|
| Rate for Payer: Cigna Commercial |
$3,500.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,211.00
|
| Rate for Payer: Health EOS Commercial |
$3,353.35
|
| Rate for Payer: HFN Commercial |
$3,500.75
|
| Rate for Payer: Multiplan Commercial |
$2,948.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,621.40
|
| Rate for Payer: Quartz Commercial |
$2,100.45
|
| Rate for Payer: The Alliance Commercial |
$1,842.50
|
| Rate for Payer: United Healthcare Medicaid |
$142.84
|
| Rate for Payer: WEA Trust Commercial |
$2,026.75
|
| Rate for Payer: WPS Commercial |
$2,729.48
|
|
