|
FISH, SRY/X DNA Probe
|
Facility
|
OP
|
$271.00
|
|
|
Service Code
|
CPT 88271
|
| Hospital Charge Code |
4253608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.36 |
| Max. Negotiated Rate |
$249.32 |
| Rate for Payer: Aetna Commercial |
$243.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.06
|
| Rate for Payer: Aetna Managed Medicare |
$21.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.56
|
| Rate for Payer: Anthem Medicaid |
$20.36
|
| Rate for Payer: Anthem Medicare Advantage |
$21.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.42
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$249.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.65
|
| Rate for Payer: Dean Health Medicaid |
$20.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.42
|
| Rate for Payer: Health EOS Commercial |
$241.19
|
| Rate for Payer: HFN Commercial |
$249.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.42
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.42
|
| Rate for Payer: Managed Health Services Medicaid |
$21.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.42
|
| Rate for Payer: Multiplan Commercial |
$216.80
|
| Rate for Payer: NAPHCARE Commercial |
$32.13
|
| Rate for Payer: Preferred Network Access Commercial |
$249.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20.36
|
| Rate for Payer: Quartz Beloit One Network |
$132.79
|
| Rate for Payer: Quartz Commercial |
$176.15
|
| Rate for Payer: Quartz Medicare Advantage |
$21.42
|
| Rate for Payer: The Alliance Commercial |
$85.68
|
| Rate for Payer: United Healthcare Medicaid |
$20.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.42
|
| Rate for Payer: United Healthcare PPO |
$203.25
|
| Rate for Payer: WEA Trust Commercial |
$149.05
|
| Rate for Payer: Wellcare Medicare |
$21.42
|
| Rate for Payer: WMAP Medicaid |
$20.36
|
| Rate for Payer: WPS Commercial |
$200.73
|
|
|
FISH, SRY/X DNA Probe
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
CPT 88271
|
| Hospital Charge Code |
4253608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$249.32 |
| Rate for Payer: Aetna Commercial |
$243.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.63
|
| Rate for Payer: Cash Price |
$81.30
|
| Rate for Payer: Cigna Commercial |
$249.32
|
| Rate for Payer: Health EOS Commercial |
$241.19
|
| Rate for Payer: HFN Commercial |
$249.32
|
| Rate for Payer: Multiplan Commercial |
$216.80
|
| Rate for Payer: NAPHCARE Commercial |
$162.60
|
| Rate for Payer: Preferred Network Access Commercial |
$249.32
|
| Rate for Payer: Quartz Beloit One Network |
$132.79
|
| Rate for Payer: Quartz Commercial |
$162.60
|
| Rate for Payer: WEA Trust Commercial |
$149.05
|
| Rate for Payer: WPS Commercial |
$200.73
|
|
|
FISH, SRY/X Interp & Report
|
Professional
|
Both
|
$184.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4253610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Anthem Commercial |
$5.66
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$167.44
|
| Rate for Payer: HFN Commercial |
$174.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.07
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: Preferred Network Access Commercial |
$174.80
|
| Rate for Payer: Quartz Beloit One Network |
$80.96
|
| Rate for Payer: Quartz Commercial |
$104.88
|
| Rate for Payer: The Alliance Commercial |
$92.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
FISH, SRY/X Interp & Report
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4253610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
FISH, SRY/X Interp & Report
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4253610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: United Healthcare PPO |
$138.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
FISH TargetGene Analysis
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.88 |
| Max. Negotiated Rate |
$263.15 |
| Rate for Payer: Aetna Commercial |
$263.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$263.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$138.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.20
|
| Rate for Payer: Health EOS Commercial |
$252.07
|
| Rate for Payer: HFN Commercial |
$263.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.70
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.15
|
| Rate for Payer: Quartz Beloit One Network |
$121.88
|
| Rate for Payer: Quartz Commercial |
$157.89
|
| Rate for Payer: The Alliance Commercial |
$138.50
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
FISH TargetGene Analysis
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
FISH TargetGene Analysis
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
4514695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.19 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$51.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$191.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.98
|
| Rate for Payer: Anthem Medicaid |
$52.89
|
| Rate for Payer: Anthem Medicare Advantage |
$51.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.19
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$51.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Dean Health Medicaid |
$52.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$51.19
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$190.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$52.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.19
|
| Rate for Payer: Managed Health Services Medicaid |
$55.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$51.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$51.19
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$76.78
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52.89
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$51.19
|
| Rate for Payer: The Alliance Commercial |
$204.76
|
| Rate for Payer: United Healthcare Medicaid |
$52.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.19
|
| Rate for Payer: United Healthcare PPO |
$207.75
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: Wellcare Medicare |
$51.19
|
| Rate for Payer: WMAP Medicaid |
$52.89
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
FISTULA PRESSURE CLAMP
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2972360
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$73.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.06
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$156.60
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
FISTULA PRESSURE CLAMP
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2972360
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
Fistula Tract Procedure
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$417.97 |
| Max. Negotiated Rate |
$784.76 |
| Rate for Payer: Aetna Commercial |
$767.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$733.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.09
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$784.76
|
| Rate for Payer: Health EOS Commercial |
$759.17
|
| Rate for Payer: HFN Commercial |
$784.76
|
| Rate for Payer: Multiplan Commercial |
$682.40
|
| Rate for Payer: NAPHCARE Commercial |
$511.80
|
| Rate for Payer: Preferred Network Access Commercial |
$784.76
|
| Rate for Payer: Quartz Beloit One Network |
$417.97
|
| Rate for Payer: Quartz Commercial |
$511.80
|
| Rate for Payer: WEA Trust Commercial |
$469.15
|
| Rate for Payer: WPS Commercial |
$631.82
|
|
|
Fistula Tract Procedure
|
Professional
|
Both
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$205.23 |
| Max. Negotiated Rate |
$810.35 |
| Rate for Payer: Aetna Commercial |
$810.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$733.58
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$810.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$426.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$511.80
|
| Rate for Payer: Health EOS Commercial |
$776.23
|
| Rate for Payer: HFN Commercial |
$810.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$205.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$205.23
|
| Rate for Payer: Multiplan Commercial |
$682.40
|
| Rate for Payer: Preferred Network Access Commercial |
$810.35
|
| Rate for Payer: Quartz Beloit One Network |
$375.32
|
| Rate for Payer: Quartz Commercial |
$486.21
|
| Rate for Payer: The Alliance Commercial |
$426.50
|
| Rate for Payer: WEA Trust Commercial |
$469.15
|
| Rate for Payer: WPS Commercial |
$631.82
|
|
|
Fistula Tract Procedure
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$2,181.12 |
| Rate for Payer: Aetna Commercial |
$767.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$733.58
|
| Rate for Payer: Aetna Managed Medicare |
$545.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,044.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,635.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,554.05
|
| Rate for Payer: Anthem Medicare Advantage |
$545.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$545.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$545.28
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$784.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$545.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$545.28
|
| Rate for Payer: Health EOS Commercial |
$759.17
|
| Rate for Payer: HFN Commercial |
$784.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,028.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$545.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$545.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$545.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$545.28
|
| Rate for Payer: Multiplan Commercial |
$682.40
|
| Rate for Payer: NAPHCARE Commercial |
$817.92
|
| Rate for Payer: Preferred Network Access Commercial |
$784.76
|
| Rate for Payer: Quartz Beloit One Network |
$417.97
|
| Rate for Payer: Quartz Commercial |
$554.45
|
| Rate for Payer: Quartz Medicare Advantage |
$545.28
|
| Rate for Payer: The Alliance Commercial |
$2,181.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$545.28
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$469.15
|
| Rate for Payer: Wellcare Medicare |
$545.28
|
| Rate for Payer: WPS Commercial |
$631.82
|
|
|
FISTULECTOMY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960382
|
|
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
|
|
|
FISTULECTOMY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960382
|
|
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
|
|
|
Fitting And Insertion Of Pessary
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
CPT 57160
|
| Hospital Charge Code |
1188877
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$154.19 |
| Rate for Payer: Aetna Commercial |
$80.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$80.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.00
|
| Rate for Payer: Health EOS Commercial |
$77.35
|
| Rate for Payer: HFN Commercial |
$80.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$154.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.19
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: Preferred Network Access Commercial |
$80.75
|
| Rate for Payer: Quartz Beloit One Network |
$37.40
|
| Rate for Payer: Quartz Commercial |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$42.50
|
| Rate for Payer: United Healthcare Medicaid |
$15.06
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
FITTING OF DIAPHRAGM/CAP 57170
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
3015072
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$31.06 |
| Max. Negotiated Rate |
$328.70 |
| Rate for Payer: Aetna Commercial |
$328.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$297.56
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$328.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.60
|
| Rate for Payer: Health EOS Commercial |
$314.86
|
| Rate for Payer: HFN Commercial |
$328.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.18
|
| Rate for Payer: Multiplan Commercial |
$276.80
|
| Rate for Payer: Preferred Network Access Commercial |
$328.70
|
| Rate for Payer: Quartz Beloit One Network |
$152.24
|
| Rate for Payer: Quartz Commercial |
$197.22
|
| Rate for Payer: The Alliance Commercial |
$173.00
|
| Rate for Payer: United Healthcare Medicaid |
$31.06
|
| Rate for Payer: WEA Trust Commercial |
$190.30
|
| Rate for Payer: WPS Commercial |
$256.28
|
|
|
FIXATION PACK LAPIPLASTY LESSER TMT SK28
|
Facility
|
OP
|
$14,610.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,090.80 |
| Max. Negotiated Rate |
$58,440.00 |
| Rate for Payer: Aetna Commercial |
$13,149.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,564.60
|
| Rate for Payer: Aetna Managed Medicare |
$4,090.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,496.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,305.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,012.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,743.30
|
| Rate for Payer: Cash Price |
$4,383.00
|
| Rate for Payer: Cigna Commercial |
$13,441.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,175.76
|
| Rate for Payer: Health EOS Commercial |
$13,002.90
|
| Rate for Payer: HFN Commercial |
$13,441.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,957.50
|
| Rate for Payer: Multiplan Commercial |
$11,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,766.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,441.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,158.90
|
| Rate for Payer: Quartz Commercial |
$9,496.50
|
| Rate for Payer: Quartz Medicare Advantage |
$8,766.00
|
| Rate for Payer: The Alliance Commercial |
$58,440.00
|
| Rate for Payer: WEA Trust Commercial |
$8,035.50
|
| Rate for Payer: WPS Commercial |
$10,821.63
|
|
|
FIXATION PACK LAPIPLASTY LESSER TMT SK28
|
Facility
|
IP
|
$14,610.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,158.90 |
| Max. Negotiated Rate |
$13,441.20 |
| Rate for Payer: Aetna Commercial |
$13,149.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,564.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,743.30
|
| Rate for Payer: Cash Price |
$4,383.00
|
| Rate for Payer: Cigna Commercial |
$13,441.20
|
| Rate for Payer: Health EOS Commercial |
$13,002.90
|
| Rate for Payer: HFN Commercial |
$13,441.20
|
| Rate for Payer: Multiplan Commercial |
$11,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,766.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,441.20
|
| Rate for Payer: Quartz Beloit One Network |
$7,158.90
|
| Rate for Payer: Quartz Commercial |
$8,766.00
|
| Rate for Payer: WEA Trust Commercial |
$8,035.50
|
| Rate for Payer: WPS Commercial |
$10,821.63
|
|
|
FIXATION PIN TEMPORARY 1.4MM LG 58820024
|
Facility
|
IP
|
$1,412.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5729839
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$691.88 |
| Max. Negotiated Rate |
$1,299.04 |
| Rate for Payer: Aetna Commercial |
$1,270.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,214.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$748.36
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,299.04
|
| Rate for Payer: Health EOS Commercial |
$1,256.68
|
| Rate for Payer: HFN Commercial |
$1,299.04
|
| Rate for Payer: Multiplan Commercial |
$1,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$847.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,299.04
|
| Rate for Payer: Quartz Beloit One Network |
$691.88
|
| Rate for Payer: Quartz Commercial |
$847.20
|
| Rate for Payer: WEA Trust Commercial |
$776.60
|
| Rate for Payer: WPS Commercial |
$1,045.87
|
|
|
FIXATION PIN TEMPORARY 1.4MM LG 58820024
|
Facility
|
OP
|
$1,412.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5729839
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$395.36 |
| Max. Negotiated Rate |
$5,648.00 |
| Rate for Payer: Aetna Commercial |
$1,270.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,214.32
|
| Rate for Payer: Aetna Managed Medicare |
$395.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$917.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$706.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$677.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$748.36
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,299.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$790.16
|
| Rate for Payer: Health EOS Commercial |
$1,256.68
|
| Rate for Payer: HFN Commercial |
$1,299.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,059.00
|
| Rate for Payer: Multiplan Commercial |
$1,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$847.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,299.04
|
| Rate for Payer: Quartz Beloit One Network |
$691.88
|
| Rate for Payer: Quartz Commercial |
$917.80
|
| Rate for Payer: Quartz Medicare Advantage |
$847.20
|
| Rate for Payer: The Alliance Commercial |
$5,648.00
|
| Rate for Payer: WEA Trust Commercial |
$776.60
|
| Rate for Payer: WPS Commercial |
$1,045.87
|
|
|
FIXATION STAPLE SPIKED LARGE 128696
|
Facility
|
OP
|
$2,086.00
|
|
| Hospital Charge Code |
2966012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$8,344.00 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.96
|
| Rate for Payer: Aetna Managed Medicare |
$584.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,355.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,001.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,167.33
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,564.50
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,355.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,251.60
|
| Rate for Payer: The Alliance Commercial |
$8,344.00
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
|
FIXATION STAPLE SPIKED LARGE 128696
|
Facility
|
IP
|
$2,086.00
|
|
| Hospital Charge Code |
2966012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,022.14 |
| Max. Negotiated Rate |
$1,919.12 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,251.60
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
|
FIXATION STAPLE SPIKED MEDIUM 128694
|
Facility
|
IP
|
$2,086.00
|
|
| Hospital Charge Code |
2966013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,022.14 |
| Max. Negotiated Rate |
$1,919.12 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,251.60
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
|
FIXATION STAPLE SPIKED MEDIUM 128694
|
Facility
|
OP
|
$2,086.00
|
|
| Hospital Charge Code |
2966013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.08 |
| Max. Negotiated Rate |
$8,344.00 |
| Rate for Payer: Aetna Commercial |
$1,877.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,793.96
|
| Rate for Payer: Aetna Managed Medicare |
$584.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,355.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,001.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,105.58
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,919.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,167.33
|
| Rate for Payer: Health EOS Commercial |
$1,856.54
|
| Rate for Payer: HFN Commercial |
$1,919.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,564.50
|
| Rate for Payer: Multiplan Commercial |
$1,668.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,251.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,919.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,022.14
|
| Rate for Payer: Quartz Commercial |
$1,355.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,251.60
|
| Rate for Payer: The Alliance Commercial |
$8,344.00
|
| Rate for Payer: WEA Trust Commercial |
$1,147.30
|
| Rate for Payer: WPS Commercial |
$1,545.10
|
|
