|
DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)
|
Facility
|
OP
|
$8,685.50
|
|
|
Service Code
|
CPT 56515
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,171.37 |
| Max. Negotiated Rate |
$8,685.50 |
| Rate for Payer: Aetna Managed Medicare |
$2,171.37
|
| 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 |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,171.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,171.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,171.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,171.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,077.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,171.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,171.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,171.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,171.37
|
| Rate for Payer: NAPHCARE Commercial |
$3,257.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,171.37
|
| Rate for Payer: The Alliance Commercial |
$8,685.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,171.37
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$2,171.37
|
|
|
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 |
$116.07 |
| Max. Negotiated Rate |
$522.33 |
| Rate for Payer: Aetna Commercial |
$432.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$391.75
|
| Rate for Payer: Aetna Managed Medicare |
$116.07
|
| Rate for Payer: Anthem Medicare Advantage |
$116.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$116.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$116.07
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$432.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.07
|
| Rate for Payer: Health EOS Commercial |
$414.52
|
| Rate for Payer: HFN Commercial |
$432.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$453.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$453.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$116.07
|
| Rate for Payer: Multiplan Commercial |
$364.42
|
| Rate for Payer: NAPHCARE Commercial |
$174.11
|
| Rate for Payer: Preferred Network Access Commercial |
$432.74
|
| Rate for Payer: Quartz Beloit One Network |
$200.43
|
| Rate for Payer: Quartz Commercial |
$259.65
|
| Rate for Payer: Quartz Medicare Advantage |
$116.07
|
| Rate for Payer: The Alliance Commercial |
$493.32
|
| Rate for Payer: United Healthcare Medicaid |
$118.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.07
|
| Rate for Payer: WEA Trust Commercial |
$250.54
|
| Rate for Payer: WPS Commercial |
$522.33
|
|
|
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 |
$424.60 |
| Max. Negotiated Rate |
$2,744.66 |
| Rate for Payer: Aetna Commercial |
$2,744.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,484.64
|
| Rate for Payer: Aetna Managed Medicare |
$424.60
|
| Rate for Payer: Anthem Medicare Advantage |
$424.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$424.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$424.60
|
| Rate for Payer: Cash Price |
$833.40
|
| Rate for Payer: Cash Price |
$833.40
|
| Rate for Payer: Cash Price |
$833.40
|
| Rate for Payer: Cigna Commercial |
$2,744.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$575.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$424.60
|
| Rate for Payer: Health EOS Commercial |
$2,629.10
|
| Rate for Payer: HFN Commercial |
$2,744.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,742.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,742.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$424.60
|
| Rate for Payer: Multiplan Commercial |
$2,311.30
|
| Rate for Payer: NAPHCARE Commercial |
$636.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,744.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,271.21
|
| Rate for Payer: Quartz Commercial |
$1,646.80
|
| Rate for Payer: Quartz Medicare Advantage |
$424.60
|
| Rate for Payer: The Alliance Commercial |
$1,804.55
|
| Rate for Payer: United Healthcare Medicaid |
$575.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$424.60
|
| Rate for Payer: WEA Trust Commercial |
$1,589.02
|
| Rate for Payer: WPS Commercial |
$1,910.70
|
|
|
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 |
$575.44 |
| Max. Negotiated Rate |
$5,489.33 |
| Rate for Payer: Aetna Commercial |
$5,489.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,969.29
|
| Rate for Payer: Cash Price |
$1,666.80
|
| Rate for Payer: Cash Price |
$1,666.80
|
| Rate for Payer: Cash Price |
$1,666.80
|
| Rate for Payer: Cigna Commercial |
$5,489.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$575.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,466.94
|
| Rate for Payer: Health EOS Commercial |
$5,258.20
|
| Rate for Payer: HFN Commercial |
$5,489.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,742.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,742.38
|
| Rate for Payer: Multiplan Commercial |
$4,622.59
|
| Rate for Payer: Preferred Network Access Commercial |
$5,489.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,542.43
|
| Rate for Payer: Quartz Commercial |
$3,293.60
|
| Rate for Payer: The Alliance Commercial |
$2,889.12
|
| Rate for Payer: United Healthcare Medicaid |
$575.44
|
| Rate for Payer: WEA Trust Commercial |
$3,178.03
|
| Rate for Payer: WPS Commercial |
$4,279.79
|
|
|
Destruction Of Precancerous Lesion 17000
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
CPT 17000
|
| Hospital Charge Code |
1188865
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$212.42 |
| Rate for Payer: Aetna Commercial |
$212.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.30
|
| Rate for Payer: Aetna Managed Medicare |
$47.09
|
| Rate for Payer: Anthem Medicare Advantage |
$47.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.09
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$212.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.09
|
| Rate for Payer: Health EOS Commercial |
$203.48
|
| Rate for Payer: HFN Commercial |
$212.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.09
|
| Rate for Payer: Multiplan Commercial |
$178.88
|
| Rate for Payer: NAPHCARE Commercial |
$70.64
|
| Rate for Payer: Preferred Network Access Commercial |
$212.42
|
| Rate for Payer: Quartz Beloit One Network |
$98.38
|
| Rate for Payer: Quartz Commercial |
$127.45
|
| Rate for Payer: Quartz Medicare Advantage |
$47.09
|
| Rate for Payer: The Alliance Commercial |
$200.14
|
| Rate for Payer: United Healthcare Medicaid |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.09
|
| Rate for Payer: WEA Trust Commercial |
$122.98
|
| Rate for Payer: WPS Commercial |
$211.91
|
|
|
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 |
$81.55 |
| Max. Negotiated Rate |
$577.98 |
| Rate for Payer: Aetna Commercial |
$577.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$523.22
|
| Rate for Payer: Aetna Managed Medicare |
$81.55
|
| Rate for Payer: Anthem Medicare Advantage |
$81.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$81.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$81.55
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cash Price |
$175.50
|
| Rate for Payer: Cigna Commercial |
$577.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.55
|
| Rate for Payer: Health EOS Commercial |
$553.64
|
| Rate for Payer: HFN Commercial |
$577.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$342.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$81.55
|
| Rate for Payer: Multiplan Commercial |
$486.72
|
| Rate for Payer: NAPHCARE Commercial |
$122.32
|
| Rate for Payer: Preferred Network Access Commercial |
$577.98
|
| Rate for Payer: Quartz Beloit One Network |
$267.70
|
| Rate for Payer: Quartz Commercial |
$346.79
|
| Rate for Payer: Quartz Medicare Advantage |
$81.55
|
| Rate for Payer: The Alliance Commercial |
$346.57
|
| Rate for Payer: United Healthcare Medicaid |
$182.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.55
|
| Rate for Payer: WEA Trust Commercial |
$334.62
|
| Rate for Payer: WPS Commercial |
$366.96
|
|
|
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 |
$1.73 |
| Max. Negotiated Rate |
$63.23 |
| Rate for Payer: Aetna Commercial |
$63.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.24
|
| Rate for Payer: Aetna Managed Medicare |
$1.73
|
| Rate for Payer: Anthem Medicare Advantage |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.73
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna Commercial |
$63.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.73
|
| Rate for Payer: Health EOS Commercial |
$60.57
|
| Rate for Payer: HFN Commercial |
$63.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$53.25
|
| Rate for Payer: NAPHCARE Commercial |
$2.59
|
| Rate for Payer: Preferred Network Access Commercial |
$63.23
|
| Rate for Payer: Quartz Beloit One Network |
$29.29
|
| Rate for Payer: Quartz Commercial |
$37.94
|
| Rate for Payer: Quartz Medicare Advantage |
$1.73
|
| Rate for Payer: The Alliance Commercial |
$7.34
|
| Rate for Payer: United Healthcare Medicaid |
$6.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.73
|
| Rate for Payer: WEA Trust Commercial |
$36.61
|
| Rate for Payer: WPS Commercial |
$7.77
|
|
|
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 |
$303.58 |
| Max. Negotiated Rate |
$2,634.01 |
| Rate for Payer: Aetna Commercial |
$2,634.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,384.47
|
| Rate for Payer: Aetna Managed Medicare |
$303.58
|
| Rate for Payer: Anthem Medicare Advantage |
$303.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$303.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$303.58
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,634.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$396.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.58
|
| Rate for Payer: Health EOS Commercial |
$2,523.10
|
| Rate for Payer: HFN Commercial |
$2,634.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,238.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,238.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$303.58
|
| Rate for Payer: Multiplan Commercial |
$2,218.11
|
| Rate for Payer: NAPHCARE Commercial |
$455.36
|
| Rate for Payer: Preferred Network Access Commercial |
$2,634.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,219.96
|
| Rate for Payer: Quartz Commercial |
$1,580.40
|
| Rate for Payer: Quartz Medicare Advantage |
$303.58
|
| Rate for Payer: The Alliance Commercial |
$1,290.20
|
| Rate for Payer: United Healthcare Medicaid |
$396.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$303.58
|
| Rate for Payer: WEA Trust Commercial |
$1,524.95
|
| Rate for Payer: WPS Commercial |
$1,366.09
|
|
|
DESTRUCTION, PENIS LESION(S) 54065
|
Professional
|
Both
|
$893.00
|
|
|
Service Code
|
CPT 54065
|
| Hospital Charge Code |
3015020
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.86 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$882.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$798.70
|
| Rate for Payer: Aetna Managed Medicare |
$147.95
|
| Rate for Payer: Anthem Medicare Advantage |
$147.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$147.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$147.95
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$108.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.95
|
| Rate for Payer: Health EOS Commercial |
$845.14
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$594.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$594.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$147.95
|
| Rate for Payer: Multiplan Commercial |
$742.98
|
| Rate for Payer: NAPHCARE Commercial |
$221.93
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$408.64
|
| Rate for Payer: Quartz Commercial |
$529.37
|
| Rate for Payer: Quartz Medicare Advantage |
$147.95
|
| Rate for Payer: The Alliance Commercial |
$628.79
|
| Rate for Payer: United Healthcare Medicaid |
$108.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$147.95
|
| Rate for Payer: WEA Trust Commercial |
$510.80
|
| Rate for Payer: WPS Commercial |
$665.78
|
|
|
DETECTOR CO2 FEF END TIDAL PED
|
Facility
|
OP
|
$271.00
|
|
| Hospital Charge Code |
2963448
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$78.92 |
| Max. Negotiated Rate |
$259.29 |
| Rate for Payer: Aetna Commercial |
$253.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$242.38
|
| Rate for Payer: Aetna Managed Medicare |
$78.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$183.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$140.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$135.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.38
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$259.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.72
|
| Rate for Payer: Health EOS Commercial |
$250.84
|
| Rate for Payer: HFN Commercial |
$259.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$211.38
|
| Rate for Payer: Multiplan Commercial |
$225.47
|
| Rate for Payer: NAPHCARE Commercial |
$169.10
|
| Rate for Payer: Preferred Network Access Commercial |
$259.29
|
| Rate for Payer: Quartz Beloit One Network |
$138.10
|
| Rate for Payer: Quartz Commercial |
$183.20
|
| Rate for Payer: Quartz Medicare Advantage |
$169.10
|
| Rate for Payer: The Alliance Commercial |
$140.92
|
| Rate for Payer: WEA Trust Commercial |
$155.01
|
| Rate for Payer: WPS Commercial |
$208.75
|
|
|
DETECTOR CO2 FEF END TIDAL PED
|
Facility
|
IP
|
$271.00
|
|
| Hospital Charge Code |
2963448
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$138.10 |
| Max. Negotiated Rate |
$259.29 |
| Rate for Payer: Aetna Commercial |
$253.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$242.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.38
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$259.29
|
| Rate for Payer: Health EOS Commercial |
$250.84
|
| Rate for Payer: HFN Commercial |
$259.29
|
| Rate for Payer: Multiplan Commercial |
$225.47
|
| Rate for Payer: Preferred Network Access Commercial |
$259.29
|
| Rate for Payer: Quartz Beloit One Network |
$138.10
|
| Rate for Payer: Quartz Commercial |
$169.10
|
| Rate for Payer: WEA Trust Commercial |
$155.01
|
| Rate for Payer: WPS Commercial |
$208.75
|
|
|
DETECTOR LEAK POINT EP3 DISP #LPD-3D
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
2972292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$64.06 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$64.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$148.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$109.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.04
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$171.60
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$137.28
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$148.72
|
| Rate for Payer: Quartz Medicare Advantage |
$137.28
|
| Rate for Payer: The Alliance Commercial |
$114.40
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
DETECTOR LEAK POINT EP3 DISP #LPD-3D
|
Facility
|
IP
|
$220.00
|
|
| Hospital Charge Code |
2972292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$112.11 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$137.28
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
DETECTORS CO2 FEF END-TIDAL
|
Facility
|
OP
|
$274.00
|
|
| Hospital Charge Code |
2963009
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.79 |
| Max. Negotiated Rate |
$262.16 |
| Rate for Payer: Aetna Commercial |
$256.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.07
|
| Rate for Payer: Aetna Managed Medicare |
$79.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.03
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$262.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.47
|
| Rate for Payer: Health EOS Commercial |
$253.61
|
| Rate for Payer: HFN Commercial |
$262.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.72
|
| Rate for Payer: Multiplan Commercial |
$227.97
|
| Rate for Payer: NAPHCARE Commercial |
$170.98
|
| Rate for Payer: Preferred Network Access Commercial |
$262.16
|
| Rate for Payer: Quartz Beloit One Network |
$139.63
|
| Rate for Payer: Quartz Commercial |
$185.22
|
| Rate for Payer: Quartz Medicare Advantage |
$170.98
|
| Rate for Payer: The Alliance Commercial |
$142.48
|
| Rate for Payer: WEA Trust Commercial |
$156.73
|
| Rate for Payer: WPS Commercial |
$211.06
|
|
|
DETECTORS CO2 FEF END-TIDAL
|
Facility
|
IP
|
$274.00
|
|
| Hospital Charge Code |
2963009
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$139.63 |
| Max. Negotiated Rate |
$262.16 |
| Rate for Payer: Aetna Commercial |
$256.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.03
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$262.16
|
| Rate for Payer: Health EOS Commercial |
$253.61
|
| Rate for Payer: HFN Commercial |
$262.16
|
| Rate for Payer: Multiplan Commercial |
$227.97
|
| Rate for Payer: Preferred Network Access Commercial |
$262.16
|
| Rate for Payer: Quartz Beloit One Network |
$139.63
|
| Rate for Payer: Quartz Commercial |
$170.98
|
| Rate for Payer: WEA Trust Commercial |
$156.73
|
| Rate for Payer: WPS Commercial |
$211.06
|
|
|
DEVELOPMENTAL & NEUROPSYCHOLOGICAL TESTING
|
Facility
|
OP
|
$132.43
|
|
|
Service Code
|
EAPG 00310
|
| Min. Negotiated Rate |
$127.33 |
| Max. Negotiated Rate |
$132.43 |
| Rate for Payer: Anthem Medicaid |
$127.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$127.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.33
|
| Rate for Payer: Dean Health Medicaid |
$127.33
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$127.33
|
| Rate for Payer: Managed Health Services Medicaid |
$132.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$127.33
|
| Rate for Payer: United Healthcare Medicaid |
$127.33
|
|
|
Developmental Screening 96110
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
CPT 96110
|
| Hospital Charge Code |
2990629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna Commercial |
$151.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$151.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.47
|
| Rate for Payer: Health EOS Commercial |
$144.80
|
| Rate for Payer: HFN Commercial |
$151.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.17
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$151.16
|
| Rate for Payer: Quartz Beloit One Network |
$70.01
|
| Rate for Payer: Quartz Commercial |
$90.70
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: United Healthcare Medicaid |
$10.32
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Developmental Test administration; each add 30 mins 96113
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 96113
|
| Hospital Charge Code |
5454794
|
| Min. Negotiated Rate |
$45.94 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$229.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Aetna Managed Medicare |
$45.94
|
| Rate for Payer: Anthem Medicare Advantage |
$45.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.94
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$229.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.94
|
| Rate for Payer: Health EOS Commercial |
$219.56
|
| Rate for Payer: HFN Commercial |
$229.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.94
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: NAPHCARE Commercial |
$68.91
|
| Rate for Payer: Preferred Network Access Commercial |
$229.22
|
| Rate for Payer: Quartz Beloit One Network |
$106.16
|
| Rate for Payer: Quartz Commercial |
$137.53
|
| Rate for Payer: Quartz Medicare Advantage |
$45.94
|
| Rate for Payer: The Alliance Commercial |
$114.84
|
| Rate for Payer: United Healthcare Medicaid |
$70.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.94
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$183.75
|
|
|
Developmental Test administration; first hour 96112
|
Professional
|
Both
|
$478.00
|
|
|
Service Code
|
CPT 96112
|
| Hospital Charge Code |
5454795
|
| Min. Negotiated Rate |
$107.07 |
| Max. Negotiated Rate |
$472.26 |
| Rate for Payer: Aetna Commercial |
$472.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Aetna Managed Medicare |
$107.07
|
| Rate for Payer: Anthem Medicare Advantage |
$107.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$107.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$107.07
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$472.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.07
|
| Rate for Payer: Health EOS Commercial |
$452.38
|
| Rate for Payer: HFN Commercial |
$472.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$455.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$107.07
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: NAPHCARE Commercial |
$160.60
|
| Rate for Payer: Preferred Network Access Commercial |
$472.26
|
| Rate for Payer: Quartz Beloit One Network |
$218.73
|
| Rate for Payer: Quartz Commercial |
$283.36
|
| Rate for Payer: Quartz Medicare Advantage |
$107.07
|
| Rate for Payer: The Alliance Commercial |
$267.67
|
| Rate for Payer: United Healthcare Medicaid |
$159.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.07
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$428.27
|
|
|
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 |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
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 |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
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 |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
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 |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
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 |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-050-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
