|
Legionella , PCR and Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
3710816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$6.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.07
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.45
|
| Rate for Payer: Anthem Medicare Advantage |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.90
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.90
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.90
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$10.34
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$6.90
|
| Rate for Payer: The Alliance Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.90
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$6.90
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Legionella , PCR and Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
3710816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$6.90
|
| Rate for Payer: Anthem Medicare Advantage |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.90
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.90
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.90
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$10.34
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$6.90
|
| Rate for Payer: The Alliance Commercial |
$27.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.90
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$30.34
|
|
|
Legionella , PCR and Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
3710816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Legionella Pneumophila Antibody IgG, IFA
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
978006
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$51.48
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Legionella Pneumophila Antibody IgG, IFA
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
978006
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$70.01 |
| Rate for Payer: Aetna Commercial |
$65.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$65.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$62.46
|
| Rate for Payer: HFN Commercial |
$65.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$65.21
|
| Rate for Payer: Quartz Beloit One Network |
$30.20
|
| Rate for Payer: Quartz Commercial |
$39.12
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
Legionella Pneumophila Antibody IgG, IFA
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
978006
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
Legionella Pneumophila Group 2-6,8
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$70.01 |
| Rate for Payer: Aetna Commercial |
$68.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$68.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$65.30
|
| Rate for Payer: HFN Commercial |
$68.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$68.17
|
| Rate for Payer: Quartz Beloit One Network |
$31.57
|
| Rate for Payer: Quartz Commercial |
$40.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
Legionella Pneumophila Group 2-6,8
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942936
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
Legionella Pneumophila Group 2-6,8
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942936
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| 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 |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$53.82
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
Legionella Pneumophila Serogroup 2-6,8
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942937
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$95.32
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$109.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
Legionella Pneumophila Serogroup 2-6,8
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942937
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$134.91 |
| Rate for Payer: Aetna Commercial |
$131.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.72
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$134.91
|
| Rate for Payer: Health EOS Commercial |
$130.51
|
| Rate for Payer: HFN Commercial |
$134.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$134.91
|
| Rate for Payer: Quartz Beloit One Network |
$71.85
|
| Rate for Payer: Quartz Commercial |
$87.98
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$108.61
|
|
|
Legionella Pneumophila Serogroup 2-6,8
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
CPT 86713
|
| Hospital Charge Code |
2942937
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$139.31 |
| Rate for Payer: Aetna Commercial |
$139.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$139.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$133.44
|
| Rate for Payer: HFN Commercial |
$139.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$139.31
|
| Rate for Payer: Quartz Beloit One Network |
$64.52
|
| Rate for Payer: Quartz Commercial |
$83.58
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
LEG LOOP LEG LIFT #0815-30-898
|
Facility
|
IP
|
$394.00
|
|
| Hospital Charge Code |
2971058
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$200.78 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$245.86
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
LEG LOOP LEG LIFT #0815-30-898
|
Facility
|
OP
|
$394.00
|
|
| Hospital Charge Code |
2971058
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$114.73 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$114.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$266.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.31
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.32
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$245.86
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$266.34
|
| Rate for Payer: Quartz Medicare Advantage |
$245.86
|
| Rate for Payer: The Alliance Commercial |
$204.88
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
Leneva Allograft Matrix 1.5 cc MTF - LVA01
|
Professional
|
Both
|
$563.00
|
|
| Hospital Charge Code |
5879656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.63 |
| Max. Negotiated Rate |
$556.24 |
| Rate for Payer: Aetna Commercial |
$556.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.55
|
| Rate for Payer: Cash Price |
$168.90
|
| Rate for Payer: Cigna Commercial |
$556.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$292.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$351.31
|
| Rate for Payer: Health EOS Commercial |
$532.82
|
| Rate for Payer: HFN Commercial |
$556.24
|
| Rate for Payer: Multiplan Commercial |
$468.42
|
| Rate for Payer: Preferred Network Access Commercial |
$556.24
|
| Rate for Payer: Quartz Beloit One Network |
$257.63
|
| Rate for Payer: Quartz Commercial |
$333.75
|
| Rate for Payer: The Alliance Commercial |
$292.76
|
| Rate for Payer: WEA Trust Commercial |
$322.04
|
| Rate for Payer: WPS Commercial |
$433.68
|
|
|
Leneva Allograft Matrix 1.5 cc MTF - LVA01
|
Facility
|
OP
|
$563.00
|
|
| Hospital Charge Code |
5879656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$163.95 |
| Max. Negotiated Rate |
$538.68 |
| Rate for Payer: Aetna Commercial |
$526.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.55
|
| Rate for Payer: Aetna Managed Medicare |
$163.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$380.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$292.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$281.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.33
|
| Rate for Payer: Cash Price |
$168.90
|
| Rate for Payer: Cigna Commercial |
$538.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.67
|
| Rate for Payer: Health EOS Commercial |
$521.11
|
| Rate for Payer: HFN Commercial |
$538.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$439.14
|
| Rate for Payer: Multiplan Commercial |
$468.42
|
| Rate for Payer: NAPHCARE Commercial |
$351.31
|
| Rate for Payer: Preferred Network Access Commercial |
$538.68
|
| Rate for Payer: Quartz Beloit One Network |
$286.90
|
| Rate for Payer: Quartz Commercial |
$380.59
|
| Rate for Payer: Quartz Medicare Advantage |
$351.31
|
| Rate for Payer: The Alliance Commercial |
$292.76
|
| Rate for Payer: WEA Trust Commercial |
$322.04
|
| Rate for Payer: WPS Commercial |
$433.68
|
|
|
Leneva Allograft Matrix 1.5 cc MTF - LVA01
|
Facility
|
IP
|
$563.00
|
|
| Hospital Charge Code |
5879656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.90 |
| Max. Negotiated Rate |
$538.68 |
| Rate for Payer: Aetna Commercial |
$526.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$503.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$310.33
|
| Rate for Payer: Cash Price |
$168.90
|
| Rate for Payer: Cigna Commercial |
$538.68
|
| Rate for Payer: Health EOS Commercial |
$521.11
|
| Rate for Payer: HFN Commercial |
$538.68
|
| Rate for Payer: Multiplan Commercial |
$468.42
|
| Rate for Payer: Preferred Network Access Commercial |
$538.68
|
| Rate for Payer: Quartz Beloit One Network |
$286.90
|
| Rate for Payer: Quartz Commercial |
$351.31
|
| Rate for Payer: WEA Trust Commercial |
$322.04
|
| Rate for Payer: WPS Commercial |
$433.68
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 27685
|
|
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
|
|
|
LENS 10.0 AU00T0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595155
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Aetna Managed Medicare |
$870.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,020.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,739.60
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.42
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.14
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$2,020.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.14
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 10.0 AU00T0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595155
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,523.19 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$1,865.14
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 10.0 CLAREON CNA0T0.100
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172537
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Aetna Managed Medicare |
$870.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,020.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,739.60
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.42
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.14
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$2,020.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.14
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 10.0 CLAREON CNA0T0.100
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172537
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,523.19 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$1,865.14
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 10.0 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964309
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,256.67 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,538.78
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 10.0 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964309
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Aetna Managed Medicare |
$718.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,667.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,282.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,231.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,435.21
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,923.48
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,667.02
|
| Rate for Payer: Quartz Medicare Advantage |
$1,538.78
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 10.0 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964347
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$837.27 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,025.23
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
