|
Fragile X DNA Detection
|
Facility
|
OP
|
$1,372.00
|
|
|
Service Code
|
CPT 81243
|
| Hospital Charge Code |
977952
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.46 |
| Max. Negotiated Rate |
$1,262.24 |
| Rate for Payer: Aetna Commercial |
$1,234.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,179.92
|
| Rate for Payer: Aetna Managed Medicare |
$57.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$213.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.69
|
| Rate for Payer: Anthem Medicaid |
$54.46
|
| Rate for Payer: Anthem Medicare Advantage |
$57.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$727.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$57.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$57.04
|
| Rate for Payer: Cash Price |
$411.60
|
| Rate for Payer: Cash Price |
$411.60
|
| Rate for Payer: Cigna Commercial |
$1,262.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$57.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$767.77
|
| Rate for Payer: Dean Health Medicaid |
$54.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$1,221.08
|
| Rate for Payer: HFN Commercial |
$1,262.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$212.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.04
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$54.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$57.04
|
| Rate for Payer: Managed Health Services Medicaid |
$56.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$57.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$1,097.60
|
| Rate for Payer: NAPHCARE Commercial |
$85.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,262.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$54.46
|
| Rate for Payer: Quartz Beloit One Network |
$672.28
|
| Rate for Payer: Quartz Commercial |
$891.80
|
| Rate for Payer: Quartz Medicare Advantage |
$57.04
|
| Rate for Payer: The Alliance Commercial |
$228.16
|
| Rate for Payer: United Healthcare Medicaid |
$54.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$57.04
|
| Rate for Payer: United Healthcare PPO |
$1,029.00
|
| Rate for Payer: WEA Trust Commercial |
$754.60
|
| Rate for Payer: Wellcare Medicare |
$57.04
|
| Rate for Payer: WMAP Medicaid |
$54.46
|
| Rate for Payer: WPS Commercial |
$1,016.24
|
|
|
FRAGMENTING OF KIDNEY STONE 50590
|
Professional
|
Both
|
$9,848.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
3014942
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$888.08 |
| Max. Negotiated Rate |
$9,355.60 |
| Rate for Payer: Aetna Commercial |
$9,355.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,469.28
|
| Rate for Payer: Cash Price |
$2,954.40
|
| Rate for Payer: Cash Price |
$2,954.40
|
| Rate for Payer: Cash Price |
$2,954.40
|
| Rate for Payer: Cigna Commercial |
$9,355.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,908.80
|
| Rate for Payer: Health EOS Commercial |
$8,961.68
|
| Rate for Payer: HFN Commercial |
$9,355.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,908.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,908.64
|
| Rate for Payer: Multiplan Commercial |
$7,878.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,355.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,333.12
|
| Rate for Payer: Quartz Commercial |
$5,613.36
|
| Rate for Payer: The Alliance Commercial |
$4,924.00
|
| Rate for Payer: United Healthcare Medicaid |
$888.08
|
| Rate for Payer: WEA Trust Commercial |
$5,416.40
|
| Rate for Payer: WPS Commercial |
$7,294.41
|
|
|
Fragmenting of Kidney Stone 5059022
|
Professional
|
Both
|
$11,363.00
|
|
|
Service Code
|
CPT 50590
|
| Hospital Charge Code |
5639623
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$888.08 |
| Max. Negotiated Rate |
$10,794.85 |
| Rate for Payer: Aetna Commercial |
$10,794.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,772.18
|
| Rate for Payer: Cash Price |
$3,408.90
|
| Rate for Payer: Cash Price |
$3,408.90
|
| Rate for Payer: Cash Price |
$3,408.90
|
| Rate for Payer: Cigna Commercial |
$10,794.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,817.80
|
| Rate for Payer: Health EOS Commercial |
$10,340.33
|
| Rate for Payer: HFN Commercial |
$10,794.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,908.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,908.64
|
| Rate for Payer: Multiplan Commercial |
$9,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$10,794.85
|
| Rate for Payer: Quartz Beloit One Network |
$4,999.72
|
| Rate for Payer: Quartz Commercial |
$6,476.91
|
| Rate for Payer: The Alliance Commercial |
$5,681.50
|
| Rate for Payer: United Healthcare Medicaid |
$888.08
|
| Rate for Payer: WEA Trust Commercial |
$6,249.65
|
| Rate for Payer: WPS Commercial |
$8,416.57
|
|
|
Fragmenting of Kidney Stone 5059050
|
Professional
|
Both
|
$15,151.00
|
|
|
Service Code
|
CPT 50590 50
|
| Hospital Charge Code |
5432714
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$888.08 |
| Max. Negotiated Rate |
$14,393.45 |
| Rate for Payer: Aetna Commercial |
$14,393.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,029.86
|
| Rate for Payer: Cash Price |
$4,545.30
|
| Rate for Payer: Cash Price |
$4,545.30
|
| Rate for Payer: Cash Price |
$4,545.30
|
| Rate for Payer: Cigna Commercial |
$14,393.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,090.60
|
| Rate for Payer: Health EOS Commercial |
$13,787.41
|
| Rate for Payer: HFN Commercial |
$14,393.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,908.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,908.64
|
| Rate for Payer: Multiplan Commercial |
$12,120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,393.45
|
| Rate for Payer: Quartz Beloit One Network |
$6,666.44
|
| Rate for Payer: Quartz Commercial |
$8,636.07
|
| Rate for Payer: The Alliance Commercial |
$7,575.50
|
| Rate for Payer: United Healthcare Medicaid |
$888.08
|
| Rate for Payer: WEA Trust Commercial |
$8,333.05
|
| Rate for Payer: WPS Commercial |
$11,222.35
|
|
|
FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z-PLASTY)
|
Facility
|
OP
|
$12,729.16
|
|
|
Service Code
|
CPT 41520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,726.00 |
| Max. Negotiated Rate |
$12,729.16 |
| Rate for Payer: Aetna Managed Medicare |
$3,182.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,182.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,182.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,182.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,182.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,838.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,182.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,182.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,182.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,182.29
|
| Rate for Payer: NAPHCARE Commercial |
$4,773.44
|
| Rate for Payer: Quartz Medicare Advantage |
$3,182.29
|
| Rate for Payer: The Alliance Commercial |
$12,729.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,182.29
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$3,182.29
|
|
|
FRENULECTOMY/FRENOTOMY/FRENULOPLASTY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960079
|
|
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
|
|
|
FRENULECTOMY/FRENOTOMY/FRENULOPLASTY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960079
|
|
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
|
|
|
Fructosamine
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 82985
|
| Hospital Charge Code |
633732
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$16.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.82
|
| Rate for Payer: Anthem Medicaid |
$16.62
|
| Rate for Payer: Anthem Medicare Advantage |
$16.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.76
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Dean Health Medicaid |
$16.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.76
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.76
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.76
|
| Rate for Payer: Managed Health Services Medicaid |
$17.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.76
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.14
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.62
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.76
|
| Rate for Payer: The Alliance Commercial |
$67.04
|
| Rate for Payer: United Healthcare Medicaid |
$16.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.76
|
| Rate for Payer: United Healthcare PPO |
$110.25
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: Wellcare Medicare |
$16.76
|
| Rate for Payer: WMAP Medicaid |
$16.62
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Fructosamine
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
CPT 82985
|
| Hospital Charge Code |
633732
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.16 |
| Max. Negotiated Rate |
$139.65 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.20
|
| Rate for Payer: Health EOS Commercial |
$133.77
|
| Rate for Payer: HFN Commercial |
$139.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.16
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$139.65
|
| Rate for Payer: Quartz Beloit One Network |
$64.68
|
| Rate for Payer: Quartz Commercial |
$83.79
|
| Rate for Payer: The Alliance Commercial |
$73.50
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Fructosamine
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 82985
|
| Hospital Charge Code |
633732
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Fructose, Semen
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 82757
|
| Hospital Charge Code |
5528670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Fructose, Semen
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 82757
|
| Hospital Charge Code |
5528670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Aetna Managed Medicare |
$17.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.78
|
| Rate for Payer: Anthem Medicaid |
$8.76
|
| Rate for Payer: Anthem Medicare Advantage |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.34
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.59
|
| Rate for Payer: Dean Health Medicaid |
$8.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.34
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.34
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.34
|
| Rate for Payer: Managed Health Services Medicaid |
$9.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.34
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$26.01
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$148.20
|
| Rate for Payer: Quartz Medicare Advantage |
$17.34
|
| Rate for Payer: The Alliance Commercial |
$69.36
|
| Rate for Payer: United Healthcare Medicaid |
$8.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.34
|
| Rate for Payer: United Healthcare PPO |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: Wellcare Medicare |
$17.34
|
| Rate for Payer: WMAP Medicaid |
$8.76
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Fructose, Semen
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
CPT 82757
|
| Hospital Charge Code |
5528670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.21 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Aetna Commercial |
$216.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$216.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.80
|
| Rate for Payer: Health EOS Commercial |
$207.48
|
| Rate for Payer: HFN Commercial |
$216.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.21
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$216.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.32
|
| Rate for Payer: Quartz Commercial |
$129.96
|
| Rate for Payer: The Alliance Commercial |
$114.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Frz Plasma CPD
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
1052865
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Frz Plasma CPD
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
1052865
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$38.65 |
| Max. Negotiated Rate |
$331.80 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$82.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$231.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$170.88
|
| Rate for Payer: Anthem Medicaid |
$38.65
|
| Rate for Payer: Anthem Medicare Advantage |
$82.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.95
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$82.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Dean Health Medicaid |
$38.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$82.95
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$308.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$38.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.95
|
| Rate for Payer: Managed Health Services Medicaid |
$40.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$82.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$82.95
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$124.42
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$38.65
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$82.95
|
| Rate for Payer: The Alliance Commercial |
$331.80
|
| Rate for Payer: United Healthcare Medicaid |
$38.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.95
|
| Rate for Payer: United Healthcare PPO |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: Wellcare Medicare |
$82.95
|
| Rate for Payer: WMAP Medicaid |
$38.65
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
FSH and LH, Pediatrics
|
Professional
|
Both
|
$106.69
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.94 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Aetna Commercial |
$101.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.75
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cigna Commercial |
$101.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.01
|
| Rate for Payer: Health EOS Commercial |
$97.09
|
| Rate for Payer: HFN Commercial |
$101.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.59
|
| Rate for Payer: Multiplan Commercial |
$85.35
|
| Rate for Payer: Preferred Network Access Commercial |
$101.36
|
| Rate for Payer: Quartz Beloit One Network |
$46.94
|
| Rate for Payer: Quartz Commercial |
$60.81
|
| Rate for Payer: The Alliance Commercial |
$53.34
|
| Rate for Payer: WEA Trust Commercial |
$58.68
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
FSH and LH, Pediatrics
|
Facility
|
OP
|
$106.69
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$98.15 |
| Rate for Payer: Aetna Commercial |
$96.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.75
|
| Rate for Payer: Aetna Managed Medicare |
$18.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.84
|
| Rate for Payer: Anthem Medicaid |
$19.20
|
| Rate for Payer: Anthem Medicare Advantage |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.58
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cigna Commercial |
$98.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.70
|
| Rate for Payer: Dean Health Medicaid |
$19.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.58
|
| Rate for Payer: Health EOS Commercial |
$94.95
|
| Rate for Payer: HFN Commercial |
$98.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.58
|
| Rate for Payer: Managed Health Services Medicaid |
$19.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.58
|
| Rate for Payer: Multiplan Commercial |
$85.35
|
| Rate for Payer: NAPHCARE Commercial |
$27.87
|
| Rate for Payer: Preferred Network Access Commercial |
$98.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.20
|
| Rate for Payer: Quartz Beloit One Network |
$52.28
|
| Rate for Payer: Quartz Commercial |
$69.35
|
| Rate for Payer: Quartz Medicare Advantage |
$18.58
|
| Rate for Payer: The Alliance Commercial |
$74.32
|
| Rate for Payer: United Healthcare Medicaid |
$19.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.58
|
| Rate for Payer: United Healthcare PPO |
$80.02
|
| Rate for Payer: WEA Trust Commercial |
$58.68
|
| Rate for Payer: Wellcare Medicare |
$18.58
|
| Rate for Payer: WMAP Medicaid |
$19.20
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
FSH and LH, Pediatrics
|
Facility
|
IP
|
$106.69
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.28 |
| Max. Negotiated Rate |
$98.15 |
| Rate for Payer: Aetna Commercial |
$96.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$91.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.55
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cigna Commercial |
$98.15
|
| Rate for Payer: Health EOS Commercial |
$94.95
|
| Rate for Payer: HFN Commercial |
$98.15
|
| Rate for Payer: Multiplan Commercial |
$85.35
|
| Rate for Payer: NAPHCARE Commercial |
$64.01
|
| Rate for Payer: Preferred Network Access Commercial |
$98.15
|
| Rate for Payer: Quartz Beloit One Network |
$52.28
|
| Rate for Payer: Quartz Commercial |
$64.01
|
| Rate for Payer: WEA Trust Commercial |
$58.68
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
FSH Pediatrics
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253746
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.00
|
| Rate for Payer: Health EOS Commercial |
$81.90
|
| Rate for Payer: HFN Commercial |
$85.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.59
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$85.50
|
| Rate for Payer: Quartz Beloit One Network |
$39.60
|
| Rate for Payer: Quartz Commercial |
$51.30
|
| Rate for Payer: The Alliance Commercial |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
FSH Pediatrics
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253746
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
FSH Pediatrics
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
4253746
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$18.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.84
|
| Rate for Payer: Anthem Medicaid |
$19.20
|
| Rate for Payer: Anthem Medicare Advantage |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.58
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Dean Health Medicaid |
$19.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.58
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.58
|
| Rate for Payer: Managed Health Services Medicaid |
$19.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.58
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.87
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.58
|
| Rate for Payer: The Alliance Commercial |
$74.32
|
| Rate for Payer: United Healthcare Medicaid |
$19.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.58
|
| Rate for Payer: United Healthcare PPO |
$67.50
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: Wellcare Medicare |
$18.58
|
| Rate for Payer: WMAP Medicaid |
$19.20
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
Ft arch suprt premold longit L3040
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
3133557
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$166.79 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.20
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: HFN Commercial |
$20.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.79
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: The Alliance Commercial |
$11.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Ft arch suprt premold longit L3040
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
3133557
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Ft arch suprt premold longit L3040
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS L3040
|
| Hospital Charge Code |
3133557
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
Ft insert ucb berkeley shell L3000
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS L3000
|
| Hospital Charge Code |
3133692
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$123.64 |
| Max. Negotiated Rate |
$1,113.15 |
| Rate for Payer: Aetna Commercial |
$266.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.66
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cash Price |
$84.30
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$140.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.60
|
| Rate for Payer: Health EOS Commercial |
$255.71
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,113.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,113.15
|
| Rate for Payer: Multiplan Commercial |
$224.80
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$123.64
|
| Rate for Payer: Quartz Commercial |
$160.17
|
| Rate for Payer: The Alliance Commercial |
$140.50
|
| Rate for Payer: WEA Trust Commercial |
$154.55
|
| Rate for Payer: WPS Commercial |
$208.14
|
|
