|
D Antigen Typing
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
5374643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$97.59 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$63.65
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
D Antigen Typing
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
5374643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$154.60 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$3.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.43
|
| Rate for Payer: Anthem Medicare Advantage |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.11
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$97.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.11
|
| Rate for Payer: Health EOS Commercial |
$94.41
|
| Rate for Payer: HFN Commercial |
$97.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$4.66
|
| Rate for Payer: Preferred Network Access Commercial |
$97.59
|
| Rate for Payer: Quartz Beloit One Network |
$51.98
|
| Rate for Payer: Quartz Commercial |
$68.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3.11
|
| Rate for Payer: The Alliance Commercial |
$12.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.11
|
| Rate for Payer: United Healthcare PPO |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: Wellcare Medicare |
$3.11
|
| Rate for Payer: WPS Commercial |
$78.57
|
|
|
D Antigen Typing
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
5374643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$100.78 |
| Rate for Payer: Aetna Commercial |
$100.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.23
|
| Rate for Payer: Aetna Managed Medicare |
$3.11
|
| Rate for Payer: Anthem Medicare Advantage |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.11
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$100.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.11
|
| Rate for Payer: Health EOS Commercial |
$96.53
|
| Rate for Payer: HFN Commercial |
$100.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$84.86
|
| Rate for Payer: NAPHCARE Commercial |
$4.66
|
| Rate for Payer: Preferred Network Access Commercial |
$100.78
|
| Rate for Payer: Quartz Beloit One Network |
$46.68
|
| Rate for Payer: Quartz Commercial |
$60.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3.11
|
| Rate for Payer: The Alliance Commercial |
$12.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.11
|
| Rate for Payer: WEA Trust Commercial |
$58.34
|
| Rate for Payer: WPS Commercial |
$13.68
|
|
|
DAPS INTRODUCTORY KIT
|
Facility
|
IP
|
$2,782.00
|
|
| Hospital Charge Code |
2973257
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,417.71 |
| Max. Negotiated Rate |
$2,661.82 |
| Rate for Payer: Aetna Commercial |
$2,603.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,488.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,533.44
|
| Rate for Payer: Cash Price |
$834.60
|
| Rate for Payer: Cigna Commercial |
$2,661.82
|
| Rate for Payer: Health EOS Commercial |
$2,575.02
|
| Rate for Payer: HFN Commercial |
$2,661.82
|
| Rate for Payer: Multiplan Commercial |
$2,314.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,661.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,417.71
|
| Rate for Payer: Quartz Commercial |
$1,735.97
|
| Rate for Payer: WEA Trust Commercial |
$1,591.30
|
| Rate for Payer: WPS Commercial |
$2,142.97
|
|
|
DAPS INTRODUCTORY KIT
|
Facility
|
OP
|
$2,782.00
|
|
| Hospital Charge Code |
2973257
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$810.12 |
| Max. Negotiated Rate |
$2,661.82 |
| Rate for Payer: Aetna Commercial |
$2,603.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,488.22
|
| Rate for Payer: Aetna Managed Medicare |
$810.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,880.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,446.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,388.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,533.44
|
| Rate for Payer: Cash Price |
$834.60
|
| Rate for Payer: Cigna Commercial |
$2,661.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,619.12
|
| Rate for Payer: Health EOS Commercial |
$2,575.02
|
| Rate for Payer: HFN Commercial |
$2,661.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,169.96
|
| Rate for Payer: Multiplan Commercial |
$2,314.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,735.97
|
| Rate for Payer: Preferred Network Access Commercial |
$2,661.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,417.71
|
| Rate for Payer: Quartz Commercial |
$1,880.63
|
| Rate for Payer: Quartz Medicare Advantage |
$1,735.97
|
| Rate for Payer: The Alliance Commercial |
$1,446.64
|
| Rate for Payer: WEA Trust Commercial |
$1,591.30
|
| Rate for Payer: WPS Commercial |
$2,142.97
|
|
|
DARTOS POUCH PROCEDURE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2959987
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
DARTOS POUCH PROCEDURE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2959987
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
DAY REHABILITATION, FULL DAY
|
Facility
|
OP
|
$108.75
|
|
|
Service Code
|
EAPG 00329
|
| Min. Negotiated Rate |
$104.57 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Anthem Medicaid |
$104.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$104.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.57
|
| Rate for Payer: Dean Health Medicaid |
$104.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$104.57
|
| Rate for Payer: Managed Health Services Medicaid |
$108.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$104.57
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$104.57
|
| Rate for Payer: United Healthcare Medicaid |
$104.57
|
|
|
DAY REHABILITATION, HALF DAY
|
Facility
|
OP
|
$81.24
|
|
|
Service Code
|
EAPG 00328
|
| Min. Negotiated Rate |
$78.11 |
| Max. Negotiated Rate |
$81.24 |
| Rate for Payer: Anthem Medicaid |
$78.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$78.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.11
|
| Rate for Payer: Dean Health Medicaid |
$78.11
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$78.11
|
| Rate for Payer: Managed Health Services Medicaid |
$81.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$78.11
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$78.11
|
| Rate for Payer: United Healthcare Medicaid |
$78.11
|
|
|
D & C AFTER DELIVERY 59160
|
Professional
|
Both
|
$1,471.00
|
|
|
Service Code
|
CPT 59160
|
| Hospital Charge Code |
3015152
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$151.34 |
| Max. Negotiated Rate |
$1,453.35 |
| Rate for Payer: Aetna Commercial |
$1,453.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,315.66
|
| Rate for Payer: Aetna Managed Medicare |
$151.34
|
| Rate for Payer: Anthem Medicare Advantage |
$151.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$151.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$151.34
|
| Rate for Payer: Cash Price |
$441.30
|
| Rate for Payer: Cash Price |
$441.30
|
| Rate for Payer: Cash Price |
$441.30
|
| Rate for Payer: Cigna Commercial |
$1,453.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$193.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.34
|
| Rate for Payer: Health EOS Commercial |
$1,392.15
|
| Rate for Payer: HFN Commercial |
$1,453.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$622.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$622.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$151.34
|
| Rate for Payer: Multiplan Commercial |
$1,223.87
|
| Rate for Payer: NAPHCARE Commercial |
$227.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,453.35
|
| Rate for Payer: Quartz Beloit One Network |
$673.13
|
| Rate for Payer: Quartz Commercial |
$872.01
|
| Rate for Payer: Quartz Medicare Advantage |
$151.34
|
| Rate for Payer: The Alliance Commercial |
$643.20
|
| Rate for Payer: United Healthcare Medicaid |
$193.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$151.34
|
| Rate for Payer: WEA Trust Commercial |
$841.41
|
| Rate for Payer: WPS Commercial |
$681.03
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC
|
Facility
|
IP
|
$52,380.64
|
|
|
Service Code
|
MSDRG 744
|
| Min. Negotiated Rate |
$16,199.20 |
| Max. Negotiated Rate |
$52,380.64 |
| Rate for Payer: Aetna Managed Medicare |
$16,199.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,709.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,269.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,558.40
|
| Rate for Payer: Anthem Medicare Advantage |
$16,199.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,199.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,199.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,199.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36,142.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,199.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,175.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,199.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,199.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,199.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,199.20
|
| Rate for Payer: NAPHCARE Commercial |
$24,298.79
|
| Rate for Payer: Quartz Medicare Advantage |
$16,199.20
|
| Rate for Payer: The Alliance Commercial |
$52,380.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,199.20
|
| Rate for Payer: United Healthcare PPO |
$29,719.78
|
| Rate for Payer: Wellcare Medicare |
$16,199.20
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC
|
Facility
|
IP
|
$28,975.44
|
|
|
Service Code
|
MSDRG 745
|
| Min. Negotiated Rate |
$9,217.99 |
| Max. Negotiated Rate |
$28,975.44 |
| Rate for Payer: Aetna Managed Medicare |
$9,217.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,819.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,023.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,073.87
|
| Rate for Payer: Anthem Medicare Advantage |
$9,217.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,217.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,217.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,217.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,063.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,217.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,008.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,217.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,217.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,217.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,217.99
|
| Rate for Payer: NAPHCARE Commercial |
$13,826.98
|
| Rate for Payer: Quartz Medicare Advantage |
$9,217.99
|
| Rate for Payer: The Alliance Commercial |
$28,975.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,217.99
|
| Rate for Payer: United Healthcare PPO |
$16,355.04
|
| Rate for Payer: Wellcare Medicare |
$9,217.99
|
|
|
D-Dimer
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
633718
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.50 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$195.31
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
D-Dimer
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
633718
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$309.24 |
| Rate for Payer: Aetna Commercial |
$309.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$10.59
|
| Rate for Payer: Anthem Medicare Advantage |
$10.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.59
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$309.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$162.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.59
|
| Rate for Payer: Health EOS Commercial |
$296.22
|
| Rate for Payer: HFN Commercial |
$309.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.59
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$15.88
|
| Rate for Payer: Preferred Network Access Commercial |
$309.24
|
| Rate for Payer: Quartz Beloit One Network |
$143.23
|
| Rate for Payer: Quartz Commercial |
$185.55
|
| Rate for Payer: Quartz Medicare Advantage |
$10.59
|
| Rate for Payer: The Alliance Commercial |
$41.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.59
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: WPS Commercial |
$46.58
|
|
|
D-Dimer
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
633718
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$299.48 |
| Rate for Payer: Aetna Commercial |
$292.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$279.95
|
| Rate for Payer: Aetna Managed Medicare |
$10.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.53
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.57
|
| Rate for Payer: Anthem Medicare Advantage |
$10.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.59
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$299.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.59
|
| Rate for Payer: Health EOS Commercial |
$289.71
|
| Rate for Payer: HFN Commercial |
$299.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.59
|
| Rate for Payer: Multiplan Commercial |
$260.42
|
| Rate for Payer: NAPHCARE Commercial |
$15.88
|
| Rate for Payer: Preferred Network Access Commercial |
$299.48
|
| Rate for Payer: Quartz Beloit One Network |
$159.50
|
| Rate for Payer: Quartz Commercial |
$211.59
|
| Rate for Payer: Quartz Medicare Advantage |
$10.59
|
| Rate for Payer: The Alliance Commercial |
$42.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.59
|
| Rate for Payer: United Healthcare PPO |
$244.14
|
| Rate for Payer: WEA Trust Commercial |
$179.04
|
| Rate for Payer: Wellcare Medicare |
$10.59
|
| Rate for Payer: WPS Commercial |
$241.10
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.93 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$287.66
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.10 |
| Max. Negotiated Rate |
$720.39 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$180.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$675.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$315.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$298.96
|
| Rate for Payer: Anthem Medicare Advantage |
$180.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$180.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$180.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$180.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$180.10
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$669.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$180.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$180.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$180.10
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$270.15
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$311.64
|
| Rate for Payer: Quartz Medicare Advantage |
$180.10
|
| Rate for Payer: The Alliance Commercial |
$720.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$180.10
|
| Rate for Payer: United Healthcare PPO |
$359.58
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: Wellcare Medicare |
$180.10
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
DEB Assay for Fanconi Anemia
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.10 |
| Max. Negotiated Rate |
$792.43 |
| Rate for Payer: Aetna Commercial |
$455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$180.10
|
| Rate for Payer: Anthem Medicare Advantage |
$180.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$180.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$180.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$455.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.10
|
| Rate for Payer: Health EOS Commercial |
$436.29
|
| Rate for Payer: HFN Commercial |
$455.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$635.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$635.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$180.10
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$270.15
|
| Rate for Payer: Preferred Network Access Commercial |
$455.47
|
| Rate for Payer: Quartz Beloit One Network |
$210.95
|
| Rate for Payer: Quartz Commercial |
$273.28
|
| Rate for Payer: Quartz Medicare Advantage |
$180.10
|
| Rate for Payer: The Alliance Commercial |
$711.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$180.10
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$792.43
|
|
|
DEB Assay for Fanconi Anemia
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$455.47 |
| Rate for Payer: Aetna Commercial |
$455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$33.24
|
| Rate for Payer: Anthem Commercial |
$5.89
|
| Rate for Payer: Anthem Medicare Advantage |
$33.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.24
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$455.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.24
|
| Rate for Payer: Health EOS Commercial |
$436.29
|
| Rate for Payer: HFN Commercial |
$455.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$117.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.24
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$49.86
|
| Rate for Payer: Preferred Network Access Commercial |
$455.47
|
| Rate for Payer: Quartz Beloit One Network |
$210.95
|
| Rate for Payer: Quartz Commercial |
$273.28
|
| Rate for Payer: Quartz Medicare Advantage |
$33.24
|
| Rate for Payer: The Alliance Commercial |
$131.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.24
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$146.25
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$132.95 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Aetna Managed Medicare |
$134.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.30
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$359.58
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: NAPHCARE Commercial |
$287.66
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$311.64
|
| Rate for Payer: Quartz Medicare Advantage |
$287.66
|
| Rate for Payer: The Alliance Commercial |
$132.95
|
| Rate for Payer: United Healthcare PPO |
$359.58
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$234.93 |
| Max. Negotiated Rate |
$441.08 |
| Rate for Payer: Aetna Commercial |
$431.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.10
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$441.08
|
| Rate for Payer: Health EOS Commercial |
$426.70
|
| Rate for Payer: HFN Commercial |
$441.08
|
| Rate for Payer: Multiplan Commercial |
$383.55
|
| Rate for Payer: Preferred Network Access Commercial |
$441.08
|
| Rate for Payer: Quartz Beloit One Network |
$234.93
|
| Rate for Payer: Quartz Commercial |
$287.66
|
| Rate for Payer: WEA Trust Commercial |
$263.69
|
| Rate for Payer: WPS Commercial |
$355.11
|
|
|
DEBRIDE INFECTED SKIN 11000
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 11000
|
| Hospital Charge Code |
3013510
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$245.02 |
| Rate for Payer: Aetna Commercial |
$245.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$24.02
|
| Rate for Payer: Anthem Medicare Advantage |
$24.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.02
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$245.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.02
|
| Rate for Payer: Health EOS Commercial |
$234.71
|
| Rate for Payer: HFN Commercial |
$245.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$98.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.02
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$36.04
|
| Rate for Payer: Preferred Network Access Commercial |
$245.02
|
| Rate for Payer: Quartz Beloit One Network |
$113.48
|
| Rate for Payer: Quartz Commercial |
$147.01
|
| Rate for Payer: Quartz Medicare Advantage |
$24.02
|
| Rate for Payer: The Alliance Commercial |
$102.10
|
| Rate for Payer: United Healthcare Medicaid |
$33.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.02
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$108.11
|
|
|
DEBRIDE INFECTED SKIN ADD-ON 11001
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
CPT 11001
|
| Hospital Charge Code |
3013511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.39 |
| Max. Negotiated Rate |
$94.85 |
| Rate for Payer: Aetna Commercial |
$94.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$12.39
|
| Rate for Payer: Anthem Medicare Advantage |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.39
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$94.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.39
|
| Rate for Payer: Health EOS Commercial |
$90.85
|
| Rate for Payer: HFN Commercial |
$94.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.39
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$18.58
|
| Rate for Payer: Preferred Network Access Commercial |
$94.85
|
| Rate for Payer: Quartz Beloit One Network |
$43.93
|
| Rate for Payer: Quartz Commercial |
$56.91
|
| Rate for Payer: Quartz Medicare Advantage |
$12.39
|
| Rate for Payer: The Alliance Commercial |
$52.64
|
| Rate for Payer: United Healthcare Medicaid |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.39
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$55.74
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,947.89
|
|
|
Service Code
|
CPT 11047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$318.12 |
| Max. Negotiated Rate |
$4,947.89 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: The Alliance Commercial |
$318.12
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$6,952.48
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,738.12 |
| Max. Negotiated Rate |
$6,952.48 |
| Rate for Payer: Aetna Managed Medicare |
$1,738.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,738.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,738.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,738.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,738.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,738.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,465.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,738.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,738.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,738.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,738.12
|
| Rate for Payer: NAPHCARE Commercial |
$2,607.18
|
| Rate for Payer: Quartz Medicare Advantage |
$1,738.12
|
| Rate for Payer: The Alliance Commercial |
$6,952.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,738.12
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$1,738.12
|
|
