|
ENDODONTICS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
ENDOLYMPHADIC SHUNT
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960009
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
ENDOLYMPHADIC SHUNT
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960009
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
ENDOMETR ABLATE, THERMAL 58353
|
Professional
|
Both
|
$1,687.00
|
|
|
Service Code
|
CPT 58353
|
| Hospital Charge Code |
3015110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$742.28 |
| Max. Negotiated Rate |
$1,602.65 |
| Rate for Payer: Aetna Commercial |
$1,602.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,450.82
|
| Rate for Payer: Cash Price |
$506.10
|
| Rate for Payer: Cash Price |
$506.10
|
| Rate for Payer: Cigna Commercial |
$1,602.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$787.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,012.20
|
| Rate for Payer: Health EOS Commercial |
$1,535.17
|
| Rate for Payer: HFN Commercial |
$1,602.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$767.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$767.39
|
| Rate for Payer: Multiplan Commercial |
$1,349.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,602.65
|
| Rate for Payer: Quartz Beloit One Network |
$742.28
|
| Rate for Payer: Quartz Commercial |
$961.59
|
| Rate for Payer: The Alliance Commercial |
$843.50
|
| Rate for Payer: United Healthcare Medicaid |
$787.58
|
| Rate for Payer: WEA Trust Commercial |
$927.85
|
| Rate for Payer: WPS Commercial |
$1,249.56
|
|
|
ENDOMETRIAL ABLATION, NOVASURE
|
Facility
|
OP
|
$1,373.00
|
|
| Hospital Charge Code |
2960253
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$384.44 |
| Max. Negotiated Rate |
$5,492.00 |
| Rate for Payer: Aetna Commercial |
$1,235.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,180.78
|
| Rate for Payer: Aetna Managed Medicare |
$384.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$892.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$686.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.69
|
| Rate for Payer: Cash Price |
$411.90
|
| Rate for Payer: Cigna Commercial |
$1,263.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.33
|
| Rate for Payer: Health EOS Commercial |
$1,221.97
|
| Rate for Payer: HFN Commercial |
$1,263.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,029.75
|
| Rate for Payer: Multiplan Commercial |
$1,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$823.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.16
|
| Rate for Payer: Quartz Beloit One Network |
$672.77
|
| Rate for Payer: Quartz Commercial |
$892.45
|
| Rate for Payer: Quartz Medicare Advantage |
$823.80
|
| Rate for Payer: The Alliance Commercial |
$5,492.00
|
| Rate for Payer: WEA Trust Commercial |
$755.15
|
| Rate for Payer: WPS Commercial |
$1,016.98
|
|
|
ENDOMETRIAL ABLATION, NOVASURE
|
Facility
|
IP
|
$1,373.00
|
|
| Hospital Charge Code |
2960253
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$672.77 |
| Max. Negotiated Rate |
$1,263.16 |
| Rate for Payer: Aetna Commercial |
$1,235.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,180.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.69
|
| Rate for Payer: Cash Price |
$411.90
|
| Rate for Payer: Cigna Commercial |
$1,263.16
|
| Rate for Payer: Health EOS Commercial |
$1,221.97
|
| Rate for Payer: HFN Commercial |
$1,263.16
|
| Rate for Payer: Multiplan Commercial |
$1,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$823.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.16
|
| Rate for Payer: Quartz Beloit One Network |
$672.77
|
| Rate for Payer: Quartz Commercial |
$823.80
|
| Rate for Payer: WEA Trust Commercial |
$755.15
|
| Rate for Payer: WPS Commercial |
$1,016.98
|
|
|
Endometrial Aspiration 58100
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
CPT 58100
|
| Hospital Charge Code |
1188851
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.24 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$404.20
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cigna Commercial |
$446.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.00
|
| Rate for Payer: Health EOS Commercial |
$427.70
|
| Rate for Payer: HFN Commercial |
$446.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.85
|
| Rate for Payer: Multiplan Commercial |
$376.00
|
| Rate for Payer: Preferred Network Access Commercial |
$446.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.80
|
| Rate for Payer: Quartz Commercial |
$267.90
|
| Rate for Payer: The Alliance Commercial |
$235.00
|
| Rate for Payer: United Healthcare Medicaid |
$55.24
|
| Rate for Payer: WEA Trust Commercial |
$258.50
|
| Rate for Payer: WPS Commercial |
$348.13
|
|
|
ENDOMETRIAL HYDROABLATION
|
Facility
|
IP
|
$1,373.00
|
|
| Hospital Charge Code |
2960124
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$672.77 |
| Max. Negotiated Rate |
$1,263.16 |
| Rate for Payer: Aetna Commercial |
$1,235.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,180.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.69
|
| Rate for Payer: Cash Price |
$411.90
|
| Rate for Payer: Cigna Commercial |
$1,263.16
|
| Rate for Payer: Health EOS Commercial |
$1,221.97
|
| Rate for Payer: HFN Commercial |
$1,263.16
|
| Rate for Payer: Multiplan Commercial |
$1,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$823.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.16
|
| Rate for Payer: Quartz Beloit One Network |
$672.77
|
| Rate for Payer: Quartz Commercial |
$823.80
|
| Rate for Payer: WEA Trust Commercial |
$755.15
|
| Rate for Payer: WPS Commercial |
$1,016.98
|
|
|
ENDOMETRIAL HYDROABLATION
|
Facility
|
OP
|
$1,373.00
|
|
| Hospital Charge Code |
2960124
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$384.44 |
| Max. Negotiated Rate |
$5,492.00 |
| Rate for Payer: Aetna Commercial |
$1,235.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,180.78
|
| Rate for Payer: Aetna Managed Medicare |
$384.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$892.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$686.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.69
|
| Rate for Payer: Cash Price |
$411.90
|
| Rate for Payer: Cigna Commercial |
$1,263.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$768.33
|
| Rate for Payer: Health EOS Commercial |
$1,221.97
|
| Rate for Payer: HFN Commercial |
$1,263.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,029.75
|
| Rate for Payer: Multiplan Commercial |
$1,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$823.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.16
|
| Rate for Payer: Quartz Beloit One Network |
$672.77
|
| Rate for Payer: Quartz Commercial |
$892.45
|
| Rate for Payer: Quartz Medicare Advantage |
$823.80
|
| Rate for Payer: The Alliance Commercial |
$5,492.00
|
| Rate for Payer: WEA Trust Commercial |
$755.15
|
| Rate for Payer: WPS Commercial |
$1,016.98
|
|
|
ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 58100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$196.96 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$196.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$196.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$196.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$196.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$732.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$196.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$196.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$196.96
|
| Rate for Payer: NAPHCARE Commercial |
$295.44
|
| Rate for Payer: Quartz Medicare Advantage |
$196.96
|
| Rate for Payer: The Alliance Commercial |
$787.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$196.96
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$196.96
|
|
|
ENDOMETRIOSIS, FULGURATION OF
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960080
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
ENDOMETRIOSIS, FULGURATION OF
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960080
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
Endomysial Antibody
|
Professional
|
Both
|
$212.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
977934
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Aetna Commercial |
$201.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$201.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$106.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.20
|
| Rate for Payer: Health EOS Commercial |
$192.92
|
| Rate for Payer: HFN Commercial |
$201.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: Preferred Network Access Commercial |
$201.40
|
| Rate for Payer: Quartz Beloit One Network |
$93.28
|
| Rate for Payer: Quartz Commercial |
$120.84
|
| Rate for Payer: The Alliance Commercial |
$106.00
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
Endomysial Antibody
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
977934
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.88 |
| Max. Negotiated Rate |
$195.04 |
| Rate for Payer: Aetna Commercial |
$190.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.36
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$195.04
|
| Rate for Payer: Health EOS Commercial |
$188.68
|
| Rate for Payer: HFN Commercial |
$195.04
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: NAPHCARE Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$195.04
|
| Rate for Payer: Quartz Beloit One Network |
$103.88
|
| Rate for Payer: Quartz Commercial |
$127.20
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
Endomysial Antibody
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
977934
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$195.04 |
| Rate for Payer: Aetna Commercial |
$190.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.32
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cigna Commercial |
$195.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.64
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$188.68
|
| Rate for Payer: HFN Commercial |
$195.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$169.60
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$195.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$103.88
|
| Rate for Payer: Quartz Commercial |
$137.80
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$159.00
|
| Rate for Payer: WEA Trust Commercial |
$116.60
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$157.03
|
|
|
.Endomysial Antibody Titier
|
Professional
|
Both
|
$114.40
|
|
|
Service Code
|
CPT 86231
|
| Hospital Charge Code |
4558606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$108.68 |
| Rate for Payer: Aetna Commercial |
$108.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Anthem Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$34.32
|
| Rate for Payer: Cash Price |
$34.32
|
| Rate for Payer: Cigna Commercial |
$108.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.64
|
| Rate for Payer: Health EOS Commercial |
$104.10
|
| Rate for Payer: HFN Commercial |
$108.68
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$108.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.34
|
| Rate for Payer: Quartz Commercial |
$65.21
|
| Rate for Payer: The Alliance Commercial |
$57.20
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.74
|
|
|
.Endomysial Antibody Titier
|
Facility
|
IP
|
$114.40
|
|
|
Service Code
|
CPT 86231
|
| Hospital Charge Code |
4558606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$34.32
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$68.64
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.74
|
|
|
.Endomysial Antibody Titier
|
Facility
|
OP
|
$114.40
|
|
|
Service Code
|
CPT 86231
|
| Hospital Charge Code |
4558606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$12.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.07
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.09
|
| Rate for Payer: Cash Price |
$34.32
|
| Rate for Payer: Cash Price |
$34.32
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.02
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.09
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.09
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.09
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$18.14
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$74.36
|
| Rate for Payer: Quartz Medicare Advantage |
$12.09
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.09
|
| Rate for Payer: United Healthcare PPO |
$85.80
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: Wellcare Medicare |
$12.09
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$84.74
|
|
|
ENDOSCOPIC EUSTACHIAN TUBE BALLOONING
|
Facility
|
IP
|
$4,385.00
|
|
| Hospital Charge Code |
5360686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,148.65 |
| Max. Negotiated Rate |
$4,034.20 |
| Rate for Payer: Aetna Commercial |
$3,946.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,771.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,324.05
|
| Rate for Payer: Cash Price |
$1,315.50
|
| Rate for Payer: Cigna Commercial |
$4,034.20
|
| Rate for Payer: Health EOS Commercial |
$3,902.65
|
| Rate for Payer: HFN Commercial |
$4,034.20
|
| Rate for Payer: Multiplan Commercial |
$3,508.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,631.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,034.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,148.65
|
| Rate for Payer: Quartz Commercial |
$2,631.00
|
| Rate for Payer: WEA Trust Commercial |
$2,411.75
|
| Rate for Payer: WPS Commercial |
$3,247.97
|
|
|
ENDOSCOPIC EUSTACHIAN TUBE BALLOONING
|
Facility
|
OP
|
$4,385.00
|
|
| Hospital Charge Code |
5360686
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,227.80 |
| Max. Negotiated Rate |
$17,540.00 |
| Rate for Payer: Aetna Commercial |
$3,946.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,771.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,227.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,850.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,192.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,104.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,324.05
|
| Rate for Payer: Cash Price |
$1,315.50
|
| Rate for Payer: Cigna Commercial |
$4,034.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,453.85
|
| Rate for Payer: Health EOS Commercial |
$3,902.65
|
| Rate for Payer: HFN Commercial |
$4,034.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,288.75
|
| Rate for Payer: Multiplan Commercial |
$3,508.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,631.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,034.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,148.65
|
| Rate for Payer: Quartz Commercial |
$2,850.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,631.00
|
| Rate for Payer: The Alliance Commercial |
$17,540.00
|
| Rate for Payer: WEA Trust Commercial |
$2,411.75
|
| Rate for Payer: WPS Commercial |
$3,247.97
|
|
|
ENDOSCOPIC GASTROCNEMIUS RESECTION
|
Facility
|
OP
|
$4,167.00
|
|
| Hospital Charge Code |
5747691
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,166.76 |
| Max. Negotiated Rate |
$16,668.00 |
| Rate for Payer: Aetna Commercial |
$3,750.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,583.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,166.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,708.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,083.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,000.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,208.51
|
| Rate for Payer: Cash Price |
$1,250.10
|
| Rate for Payer: Cigna Commercial |
$3,833.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,331.85
|
| Rate for Payer: Health EOS Commercial |
$3,708.63
|
| Rate for Payer: HFN Commercial |
$3,833.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,125.25
|
| Rate for Payer: Multiplan Commercial |
$3,333.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,833.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,041.83
|
| Rate for Payer: Quartz Commercial |
$2,708.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,500.20
|
| Rate for Payer: The Alliance Commercial |
$16,668.00
|
| Rate for Payer: WEA Trust Commercial |
$2,291.85
|
| Rate for Payer: WPS Commercial |
$3,086.50
|
|
|
ENDOSCOPIC GASTROCNEMIUS RESECTION
|
Facility
|
IP
|
$4,167.00
|
|
| Hospital Charge Code |
5747691
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,041.83 |
| Max. Negotiated Rate |
$3,833.64 |
| Rate for Payer: Aetna Commercial |
$3,750.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,583.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,208.51
|
| Rate for Payer: Cash Price |
$1,250.10
|
| Rate for Payer: Cigna Commercial |
$3,833.64
|
| Rate for Payer: Health EOS Commercial |
$3,708.63
|
| Rate for Payer: HFN Commercial |
$3,833.64
|
| Rate for Payer: Multiplan Commercial |
$3,333.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,500.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,833.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,041.83
|
| Rate for Payer: Quartz Commercial |
$2,500.20
|
| Rate for Payer: WEA Trust Commercial |
$2,291.85
|
| Rate for Payer: WPS Commercial |
$3,086.50
|
|
|
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK
|
Facility
|
OP
|
$13,782.96
|
|
|
Service Code
|
CPT 51715
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,445.74 |
| Max. Negotiated Rate |
$13,782.96 |
| Rate for Payer: Aetna Managed Medicare |
$3,445.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,445.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,445.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,445.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,818.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,445.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,445.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,445.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,445.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,168.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,445.74
|
| Rate for Payer: The Alliance Commercial |
$13,782.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,445.74
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,445.74
|
|
|
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2950498
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2950498
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
