|
DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 54065
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| 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 |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 54060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| 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 |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
Destruction Of Lesions; Vulva, Complex 56515
|
Professional
|
Both
|
$1,431.00
|
|
|
Service Code
|
CPT 56515
|
| Hospital Charge Code |
1190843
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$195.86 |
| Max. Negotiated Rate |
$1,359.45 |
| Rate for Payer: Aetna Commercial |
$1,359.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,230.66
|
| Rate for Payer: Cash Price |
$429.30
|
| Rate for Payer: Cash Price |
$429.30
|
| Rate for Payer: Cigna Commercial |
$1,359.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$858.60
|
| Rate for Payer: Health EOS Commercial |
$1,302.21
|
| Rate for Payer: HFN Commercial |
$1,359.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$703.99
|
| Rate for Payer: Multiplan Commercial |
$1,144.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,359.45
|
| Rate for Payer: Quartz Beloit One Network |
$629.64
|
| Rate for Payer: Quartz Commercial |
$815.67
|
| Rate for Payer: The Alliance Commercial |
$715.50
|
| Rate for Payer: United Healthcare Medicaid |
$195.86
|
| Rate for Payer: WEA Trust Commercial |
$787.05
|
| Rate for Payer: WPS Commercial |
$1,059.94
|
|
|
Destruction Of Lesions; Vulva, Simple 56501
|
Professional
|
Both
|
$438.00
|
|
|
Service Code
|
CPT 56501
|
| Hospital Charge Code |
1190842
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$114.36 |
| Max. Negotiated Rate |
$436.20 |
| Rate for Payer: Aetna Commercial |
$416.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$416.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$262.80
|
| Rate for Payer: Health EOS Commercial |
$398.58
|
| Rate for Payer: HFN Commercial |
$416.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$436.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$436.20
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: Preferred Network Access Commercial |
$416.10
|
| Rate for Payer: Quartz Beloit One Network |
$192.72
|
| Rate for Payer: Quartz Commercial |
$249.66
|
| Rate for Payer: The Alliance Commercial |
$219.00
|
| Rate for Payer: United Healthcare Medicaid |
$114.36
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
Destruction of Localized Lesion of Retina, Photocoagulation
|
Professional
|
Both
|
$2,778.00
|
|
|
Service Code
|
CPT 67210
|
| Hospital Charge Code |
1188905
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$553.31 |
| Max. Negotiated Rate |
$2,639.10 |
| Rate for Payer: Aetna Commercial |
$2,639.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,389.08
|
| Rate for Payer: Cash Price |
$833.40
|
| Rate for Payer: Cash Price |
$833.40
|
| Rate for Payer: Cigna Commercial |
$2,639.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$553.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,666.80
|
| Rate for Payer: Health EOS Commercial |
$2,527.98
|
| Rate for Payer: HFN Commercial |
$2,639.10
|
| 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 |
$2,222.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,639.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,222.32
|
| Rate for Payer: Quartz Commercial |
$1,583.46
|
| Rate for Payer: The Alliance Commercial |
$1,389.00
|
| Rate for Payer: United Healthcare Medicaid |
$553.31
|
| Rate for Payer: WEA Trust Commercial |
$1,527.90
|
| Rate for Payer: WPS Commercial |
$2,057.66
|
|
|
Destruction of Localized Lesion of Retina, Photocoagulation 6721050
|
Professional
|
Both
|
$5,556.00
|
|
|
Service Code
|
CPT 67210 50
|
| Hospital Charge Code |
5492810
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,444.64 |
| Max. Negotiated Rate |
$5,278.20 |
| Rate for Payer: Aetna Commercial |
$5,278.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,778.16
|
| Rate for Payer: Cash Price |
$1,666.80
|
| Rate for Payer: Cash Price |
$1,666.80
|
| Rate for Payer: Cigna Commercial |
$5,278.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,778.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,333.60
|
| Rate for Payer: Health EOS Commercial |
$5,055.96
|
| Rate for Payer: HFN Commercial |
$5,278.20
|
| Rate for Payer: Multiplan Commercial |
$4,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,278.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,444.64
|
| Rate for Payer: Quartz Commercial |
$3,166.92
|
| Rate for Payer: The Alliance Commercial |
$2,778.00
|
| Rate for Payer: WEA Trust Commercial |
$3,055.80
|
| Rate for Payer: WPS Commercial |
$4,115.33
|
|
|
Destruction Of Precancerous Lesion 17000
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
1188865
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$204.25 |
| Rate for Payer: Aetna Commercial |
$204.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.90
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$204.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.00
|
| Rate for Payer: Health EOS Commercial |
$195.65
|
| Rate for Payer: HFN Commercial |
$204.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$181.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.37
|
| Rate for Payer: Multiplan Commercial |
$172.00
|
| Rate for Payer: Preferred Network Access Commercial |
$204.25
|
| Rate for Payer: Quartz Beloit One Network |
$94.60
|
| Rate for Payer: Quartz Commercial |
$122.55
|
| Rate for Payer: The Alliance Commercial |
$107.50
|
| Rate for Payer: United Healthcare Medicaid |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$118.25
|
| Rate for Payer: WPS Commercial |
$159.25
|
|
|
Destruction of precancerous lesions; 15 or more lesions 17004
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
CPT 17004
|
| Hospital Charge Code |
1188867
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$175.02 |
| Max. Negotiated Rate |
$555.75 |
| Rate for Payer: Aetna Commercial |
$555.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.10
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$555.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$175.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$351.00
|
| Rate for Payer: Health EOS Commercial |
$532.35
|
| Rate for Payer: HFN Commercial |
$555.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$328.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$328.96
|
| Rate for Payer: Multiplan Commercial |
$468.00
|
| Rate for Payer: Preferred Network Access Commercial |
$555.75
|
| Rate for Payer: Quartz Beloit One Network |
$257.40
|
| Rate for Payer: Quartz Commercial |
$333.45
|
| Rate for Payer: The Alliance Commercial |
$292.50
|
| Rate for Payer: United Healthcare Medicaid |
$175.02
|
| Rate for Payer: WEA Trust Commercial |
$321.75
|
| Rate for Payer: WPS Commercial |
$433.31
|
|
|
Destruction of precancerous lesions; 2-14 lesions 17003
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
CPT 17003
|
| Hospital Charge Code |
1188866
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna Commercial |
$60.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.04
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$60.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.40
|
| Rate for Payer: Health EOS Commercial |
$58.24
|
| Rate for Payer: HFN Commercial |
$60.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.24
|
| Rate for Payer: Multiplan Commercial |
$51.20
|
| Rate for Payer: Preferred Network Access Commercial |
$60.80
|
| Rate for Payer: Quartz Beloit One Network |
$28.16
|
| Rate for Payer: Quartz Commercial |
$36.48
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: United Healthcare Medicaid |
$6.33
|
| Rate for Payer: WEA Trust Commercial |
$35.20
|
| Rate for Payer: WPS Commercial |
$47.40
|
|
|
Destruction of Skin Lesions 17107
|
Professional
|
Both
|
$2,666.00
|
|
|
Service Code
|
CPT 17107
|
| Hospital Charge Code |
4422915
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$381.71 |
| Max. Negotiated Rate |
$2,532.70 |
| Rate for Payer: Aetna Commercial |
$2,532.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,292.76
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,532.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$381.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,599.60
|
| Rate for Payer: Health EOS Commercial |
$2,426.06
|
| Rate for Payer: HFN Commercial |
$2,532.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,190.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,190.56
|
| Rate for Payer: Multiplan Commercial |
$2,132.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,532.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.04
|
| Rate for Payer: Quartz Commercial |
$1,519.62
|
| Rate for Payer: The Alliance Commercial |
$1,333.00
|
| Rate for Payer: United Healthcare Medicaid |
$381.71
|
| Rate for Payer: WEA Trust Commercial |
$1,466.30
|
| Rate for Payer: WPS Commercial |
$1,974.71
|
|
|
DESTRUCTION, PENIS LESION(S) 54065
|
Professional
|
Both
|
$893.00
|
|
|
Service Code
|
CPT 54065
|
| Hospital Charge Code |
3015020
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.67 |
| Max. Negotiated Rate |
$848.35 |
| Rate for Payer: Aetna Commercial |
$848.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$767.98
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cigna Commercial |
$848.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$535.80
|
| Rate for Payer: Health EOS Commercial |
$812.63
|
| Rate for Payer: HFN Commercial |
$848.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$572.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$572.11
|
| Rate for Payer: Multiplan Commercial |
$714.40
|
| Rate for Payer: Preferred Network Access Commercial |
$848.35
|
| Rate for Payer: Quartz Beloit One Network |
$392.92
|
| Rate for Payer: Quartz Commercial |
$509.01
|
| Rate for Payer: The Alliance Commercial |
$446.50
|
| Rate for Payer: United Healthcare Medicaid |
$104.67
|
| Rate for Payer: WEA Trust Commercial |
$491.15
|
| Rate for Payer: WPS Commercial |
$661.45
|
|
|
DETECTOR CO2 FEF END TIDAL PED
|
Facility
|
OP
|
$271.00
|
|
| Hospital Charge Code |
2963448
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$75.88 |
| Max. Negotiated Rate |
$1,084.00 |
| Rate for Payer: Aetna Commercial |
$243.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.06
|
| Rate for Payer: Aetna Managed Medicare |
$75.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.63
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$249.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.65
|
| Rate for Payer: Health EOS Commercial |
$241.19
|
| Rate for Payer: HFN Commercial |
$249.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.25
|
| Rate for Payer: Multiplan Commercial |
$216.80
|
| Rate for Payer: NAPHCARE Commercial |
$162.60
|
| Rate for Payer: Preferred Network Access Commercial |
$249.32
|
| Rate for Payer: Quartz Beloit One Network |
$132.79
|
| Rate for Payer: Quartz Commercial |
$176.15
|
| Rate for Payer: Quartz Medicare Advantage |
$162.60
|
| Rate for Payer: The Alliance Commercial |
$1,084.00
|
| Rate for Payer: WEA Trust Commercial |
$149.05
|
| Rate for Payer: WPS Commercial |
$200.73
|
|
|
DETECTOR CO2 FEF END TIDAL PED
|
Facility
|
IP
|
$271.00
|
|
| Hospital Charge Code |
2963448
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$249.32 |
| Rate for Payer: Aetna Commercial |
$243.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.63
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$249.32
|
| Rate for Payer: Health EOS Commercial |
$241.19
|
| Rate for Payer: HFN Commercial |
$249.32
|
| Rate for Payer: Multiplan Commercial |
$216.80
|
| Rate for Payer: NAPHCARE Commercial |
$162.60
|
| Rate for Payer: Preferred Network Access Commercial |
$249.32
|
| Rate for Payer: Quartz Beloit One Network |
$132.79
|
| Rate for Payer: Quartz Commercial |
$162.60
|
| Rate for Payer: WEA Trust Commercial |
$149.05
|
| Rate for Payer: WPS Commercial |
$200.73
|
|
|
DETECTOR LEAK POINT EP3 DISP #LPD-3D
|
Facility
|
IP
|
$220.00
|
|
| Hospital Charge Code |
2972292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
DETECTOR LEAK POINT EP3 DISP #LPD-3D
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
2972292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$61.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.11
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$165.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$143.00
|
| Rate for Payer: Quartz Medicare Advantage |
$132.00
|
| Rate for Payer: The Alliance Commercial |
$880.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
DETECTORS CO2 FEF END-TIDAL
|
Facility
|
IP
|
$274.00
|
|
| Hospital Charge Code |
2963009
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.26 |
| Max. Negotiated Rate |
$252.08 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$164.40
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
DETECTORS CO2 FEF END-TIDAL
|
Facility
|
OP
|
$274.00
|
|
| Hospital Charge Code |
2963009
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.72 |
| Max. Negotiated Rate |
$1,096.00 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Aetna Managed Medicare |
$76.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.33
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$205.50
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$178.10
|
| Rate for Payer: Quartz Medicare Advantage |
$164.40
|
| Rate for Payer: The Alliance Commercial |
$1,096.00
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
Developmental Screening 96110
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
CPT 96110
|
| Hospital Charge Code |
2990629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$145.35 |
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$145.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.80
|
| Rate for Payer: Health EOS Commercial |
$139.23
|
| Rate for Payer: HFN Commercial |
$145.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.86
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: Preferred Network Access Commercial |
$145.35
|
| Rate for Payer: Quartz Beloit One Network |
$67.32
|
| Rate for Payer: Quartz Commercial |
$87.21
|
| Rate for Payer: The Alliance Commercial |
$76.50
|
| Rate for Payer: United Healthcare Medicaid |
$9.92
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
Developmental Test administration; each add 30 mins 96113
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 96113
|
| Hospital Charge Code |
5454794
|
| Min. Negotiated Rate |
$68.13 |
| Max. Negotiated Rate |
$220.40 |
| Rate for Payer: Aetna Commercial |
$220.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.52
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$220.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$68.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.20
|
| Rate for Payer: Health EOS Commercial |
$211.12
|
| Rate for Payer: HFN Commercial |
$220.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$185.33
|
| Rate for Payer: Multiplan Commercial |
$185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$220.40
|
| Rate for Payer: Quartz Beloit One Network |
$102.08
|
| Rate for Payer: Quartz Commercial |
$132.24
|
| Rate for Payer: The Alliance Commercial |
$116.00
|
| Rate for Payer: United Healthcare Medicaid |
$68.13
|
| Rate for Payer: WEA Trust Commercial |
$127.60
|
| Rate for Payer: WPS Commercial |
$171.84
|
|
|
Developmental Test administration; first hour 96112
|
Professional
|
Both
|
$478.00
|
|
|
Service Code
|
CPT 96112
|
| Hospital Charge Code |
5454795
|
| Min. Negotiated Rate |
$152.93 |
| Max. Negotiated Rate |
$454.10 |
| Rate for Payer: Aetna Commercial |
$454.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.08
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$454.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$286.80
|
| Rate for Payer: Health EOS Commercial |
$434.98
|
| Rate for Payer: HFN Commercial |
$454.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$437.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$437.61
|
| Rate for Payer: Multiplan Commercial |
$382.40
|
| Rate for Payer: Preferred Network Access Commercial |
$454.10
|
| Rate for Payer: Quartz Beloit One Network |
$210.32
|
| Rate for Payer: Quartz Commercial |
$272.46
|
| Rate for Payer: The Alliance Commercial |
$239.00
|
| Rate for Payer: United Healthcare Medicaid |
$152.93
|
| Rate for Payer: WEA Trust Commercial |
$262.90
|
| Rate for Payer: WPS Commercial |
$354.05
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-030-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,248.39 |
| Max. Negotiated Rate |
$9,854.12 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,426.60
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-030-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-040-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,248.39 |
| Max. Negotiated Rate |
$9,854.12 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,426.60
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-040-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-050-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,999.08 |
| Max. Negotiated Rate |
$42,844.00 |
| Rate for Payer: Aetna Commercial |
$9,639.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,211.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,999.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,962.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,355.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,141.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,676.83
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$9,854.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,993.88
|
| Rate for Payer: Health EOS Commercial |
$9,532.79
|
| Rate for Payer: HFN Commercial |
$9,854.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,033.25
|
| Rate for Payer: Multiplan Commercial |
$8,568.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,854.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,248.39
|
| Rate for Payer: Quartz Commercial |
$6,962.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,426.60
|
| Rate for Payer: The Alliance Commercial |
$42,844.00
|
| Rate for Payer: WEA Trust Commercial |
$5,891.05
|
| Rate for Payer: WPS Commercial |
$7,933.64
|
|
