|
Factor X Assay
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
977944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$248.68 |
| Max. Negotiated Rate |
$466.92 |
| Rate for Payer: Aetna Commercial |
$456.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.99
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$466.92
|
| Rate for Payer: Health EOS Commercial |
$451.69
|
| Rate for Payer: HFN Commercial |
$466.92
|
| Rate for Payer: Multiplan Commercial |
$406.02
|
| Rate for Payer: Preferred Network Access Commercial |
$466.92
|
| Rate for Payer: Quartz Beloit One Network |
$248.68
|
| Rate for Payer: Quartz Commercial |
$304.51
|
| Rate for Payer: WEA Trust Commercial |
$279.14
|
| Rate for Payer: WPS Commercial |
$375.91
|
|
|
Factor X Assay
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
977944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$482.14 |
| Rate for Payer: Aetna Commercial |
$482.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.47
|
| Rate for Payer: Aetna Managed Medicare |
$18.62
|
| Rate for Payer: Anthem Medicare Advantage |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.62
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$482.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$253.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$461.84
|
| Rate for Payer: HFN Commercial |
$482.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$406.02
|
| Rate for Payer: NAPHCARE Commercial |
$27.92
|
| Rate for Payer: Preferred Network Access Commercial |
$482.14
|
| Rate for Payer: Quartz Beloit One Network |
$223.31
|
| Rate for Payer: Quartz Commercial |
$289.29
|
| Rate for Payer: Quartz Medicare Advantage |
$18.62
|
| Rate for Payer: The Alliance Commercial |
$73.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.62
|
| Rate for Payer: WEA Trust Commercial |
$279.14
|
| Rate for Payer: WPS Commercial |
$81.91
|
|
|
Factor XI Assay
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$384.33 |
| Rate for Payer: Aetna Commercial |
$384.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$18.62
|
| Rate for Payer: Anthem Medicare Advantage |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.62
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$384.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$368.15
|
| Rate for Payer: HFN Commercial |
$384.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$27.92
|
| Rate for Payer: Preferred Network Access Commercial |
$384.33
|
| Rate for Payer: Quartz Beloit One Network |
$178.01
|
| Rate for Payer: Quartz Commercial |
$230.60
|
| Rate for Payer: Quartz Medicare Advantage |
$18.62
|
| Rate for Payer: The Alliance Commercial |
$73.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.62
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$81.91
|
|
|
Factor XI Assay
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$18.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.90
|
| Rate for Payer: Anthem Medicare Advantage |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.62
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.62
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$27.92
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$262.96
|
| Rate for Payer: Quartz Medicare Advantage |
$18.62
|
| Rate for Payer: The Alliance Commercial |
$74.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.62
|
| Rate for Payer: United Healthcare PPO |
$303.42
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: Wellcare Medicare |
$18.62
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
Factor XI Assay
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.23 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$242.74
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
Factor XII Assay
|
Professional
|
Both
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.12 |
| Max. Negotiated Rate |
$391.25 |
| Rate for Payer: Aetna Commercial |
$391.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$354.18
|
| Rate for Payer: Aetna Managed Medicare |
$20.12
|
| Rate for Payer: Anthem Medicare Advantage |
$20.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.12
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$391.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$205.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.12
|
| Rate for Payer: Health EOS Commercial |
$374.77
|
| Rate for Payer: HFN Commercial |
$391.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.12
|
| Rate for Payer: Multiplan Commercial |
$329.47
|
| Rate for Payer: NAPHCARE Commercial |
$30.19
|
| Rate for Payer: Preferred Network Access Commercial |
$391.25
|
| Rate for Payer: Quartz Beloit One Network |
$181.21
|
| Rate for Payer: Quartz Commercial |
$234.75
|
| Rate for Payer: Quartz Medicare Advantage |
$20.12
|
| Rate for Payer: The Alliance Commercial |
$79.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.12
|
| Rate for Payer: WEA Trust Commercial |
$226.51
|
| Rate for Payer: WPS Commercial |
$88.55
|
|
|
Factor XII Assay
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.12 |
| Max. Negotiated Rate |
$378.89 |
| Rate for Payer: Aetna Commercial |
$370.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$354.18
|
| Rate for Payer: Aetna Managed Medicare |
$20.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.41
|
| Rate for Payer: Anthem Medicare Advantage |
$20.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.12
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$378.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.12
|
| Rate for Payer: Health EOS Commercial |
$366.54
|
| Rate for Payer: HFN Commercial |
$378.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.12
|
| Rate for Payer: Multiplan Commercial |
$329.47
|
| Rate for Payer: NAPHCARE Commercial |
$30.19
|
| Rate for Payer: Preferred Network Access Commercial |
$378.89
|
| Rate for Payer: Quartz Beloit One Network |
$201.80
|
| Rate for Payer: Quartz Commercial |
$267.70
|
| Rate for Payer: Quartz Medicare Advantage |
$20.12
|
| Rate for Payer: The Alliance Commercial |
$80.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.12
|
| Rate for Payer: United Healthcare PPO |
$308.88
|
| Rate for Payer: WEA Trust Commercial |
$226.51
|
| Rate for Payer: Wellcare Medicare |
$20.12
|
| Rate for Payer: WPS Commercial |
$305.04
|
|
|
Factor XII Assay
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$378.89 |
| Rate for Payer: Aetna Commercial |
$370.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$354.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.28
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$378.89
|
| Rate for Payer: Health EOS Commercial |
$366.54
|
| Rate for Payer: HFN Commercial |
$378.89
|
| Rate for Payer: Multiplan Commercial |
$329.47
|
| Rate for Payer: Preferred Network Access Commercial |
$378.89
|
| Rate for Payer: Quartz Beloit One Network |
$201.80
|
| Rate for Payer: Quartz Commercial |
$247.10
|
| Rate for Payer: WEA Trust Commercial |
$226.51
|
| Rate for Payer: WPS Commercial |
$305.04
|
|
|
FALSE LABOR
|
Facility
|
OP
|
$47.01
|
|
|
Service Code
|
EAPG 00764
|
| Min. Negotiated Rate |
$45.20 |
| Max. Negotiated Rate |
$47.01 |
| Rate for Payer: Anthem Medicaid |
$45.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$45.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.20
|
| Rate for Payer: Dean Health Medicaid |
$45.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$45.20
|
| Rate for Payer: Managed Health Services Medicaid |
$47.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$45.20
|
| Rate for Payer: United Healthcare Medicaid |
$45.20
|
|
|
Fam Care Observation Per Hour
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040435
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$7,271.68 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$20.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,271.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,271.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,958.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.16
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.82
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$43.06
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$46.64
|
| Rate for Payer: Quartz Medicare Advantage |
$43.06
|
| Rate for Payer: The Alliance Commercial |
$35.88
|
| Rate for Payer: United Healthcare PPO |
$2,701.92
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
Fam Care Observation Per Hour
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040435
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$43.06
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
Familial Mutation, Targeted Testing
|
Facility
|
OP
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$192.61 |
| Max. Negotiated Rate |
$770.43 |
| Rate for Payer: Aetna Commercial |
$658.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$628.76
|
| Rate for Payer: Aetna Managed Medicare |
$192.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$722.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$337.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$319.73
|
| Rate for Payer: Anthem Medicare Advantage |
$192.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$387.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$192.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$192.61
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$672.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$192.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$192.61
|
| Rate for Payer: Health EOS Commercial |
$650.70
|
| Rate for Payer: HFN Commercial |
$672.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$716.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$192.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$192.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$192.61
|
| Rate for Payer: Multiplan Commercial |
$584.90
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$672.63
|
| Rate for Payer: Quartz Beloit One Network |
$358.25
|
| Rate for Payer: Quartz Commercial |
$475.23
|
| Rate for Payer: Quartz Medicare Advantage |
$192.61
|
| Rate for Payer: The Alliance Commercial |
$770.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$192.61
|
| Rate for Payer: United Healthcare PPO |
$548.34
|
| Rate for Payer: WEA Trust Commercial |
$402.12
|
| Rate for Payer: Wellcare Medicare |
$192.61
|
| Rate for Payer: WPS Commercial |
$541.52
|
|
|
Familial Mutation, Targeted Testing
|
Facility
|
IP
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$358.25 |
| Max. Negotiated Rate |
$672.63 |
| Rate for Payer: Aetna Commercial |
$658.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$628.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$387.49
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$672.63
|
| Rate for Payer: Health EOS Commercial |
$650.70
|
| Rate for Payer: HFN Commercial |
$672.63
|
| Rate for Payer: Multiplan Commercial |
$584.90
|
| Rate for Payer: Preferred Network Access Commercial |
$672.63
|
| Rate for Payer: Quartz Beloit One Network |
$358.25
|
| Rate for Payer: Quartz Commercial |
$438.67
|
| Rate for Payer: WEA Trust Commercial |
$402.12
|
| Rate for Payer: WPS Commercial |
$541.52
|
|
|
Familial Mutation, Targeted Testing
|
Professional
|
Both
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$192.61 |
| Max. Negotiated Rate |
$847.48 |
| Rate for Payer: Aetna Commercial |
$694.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$628.76
|
| Rate for Payer: Aetna Managed Medicare |
$192.61
|
| Rate for Payer: Anthem Medicare Advantage |
$192.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$192.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$192.61
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$694.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$365.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.61
|
| Rate for Payer: Health EOS Commercial |
$665.32
|
| Rate for Payer: HFN Commercial |
$694.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$679.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$679.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$192.61
|
| Rate for Payer: Multiplan Commercial |
$584.90
|
| Rate for Payer: NAPHCARE Commercial |
$288.91
|
| Rate for Payer: Preferred Network Access Commercial |
$694.56
|
| Rate for Payer: Quartz Beloit One Network |
$321.69
|
| Rate for Payer: Quartz Commercial |
$416.74
|
| Rate for Payer: Quartz Medicare Advantage |
$192.61
|
| Rate for Payer: The Alliance Commercial |
$760.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$192.61
|
| Rate for Payer: WEA Trust Commercial |
$402.12
|
| Rate for Payer: WPS Commercial |
$847.48
|
|
|
FAMILY PSYCHOTHERAPY
|
Facility
|
OP
|
$33.42
|
|
|
Service Code
|
EAPG 00317
|
| Min. Negotiated Rate |
$32.13 |
| Max. Negotiated Rate |
$33.42 |
| Rate for Payer: Anthem Medicaid |
$32.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$32.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.13
|
| Rate for Payer: Dean Health Medicaid |
$32.13
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$32.13
|
| Rate for Payer: Managed Health Services Medicaid |
$33.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.13
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$32.13
|
| Rate for Payer: United Healthcare Medicaid |
$32.13
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$134.70 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$33.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Anthem Medicare Advantage |
$33.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.68
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$33.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$33.68
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$33.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$33.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$33.68
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$50.51
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.68
|
| Rate for Payer: The Alliance Commercial |
$134.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.68
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: Wellcare Medicare |
$33.68
|
| Rate for Payer: WPS Commercial |
$92.15
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Professional
|
Both
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$92.61 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$33.68
|
| Rate for Payer: Anthem Medicare Advantage |
$33.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.68
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.86
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.68
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$50.51
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.68
|
| Rate for Payer: The Alliance Commercial |
$92.61
|
| Rate for Payer: United Healthcare Medicaid |
$34.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.68
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$92.15
|
|
|
FASCIAL SURGICAL WOUND REPAIR
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
FASCIAL SURGICAL WOUND REPAIR
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 26121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 26123
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$8,107.14
|
|
|
Service Code
|
CPT 26125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$857.67 |
| Max. Negotiated Rate |
$8,107.14 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: The Alliance Commercial |
$857.67
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
FASCIOTOMY, FOOT AND/OR TOE
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28008
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
