|
MALT1 Cytogenetics 88275
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 88275
|
| Hospital Charge Code |
2776834
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.19 |
| Max. Negotiated Rate |
$208.84 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.22
|
| 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 |
$120.31
|
| 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 |
$68.10
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cigna Commercial |
$208.84
|
| 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 |
$127.03
|
| 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 |
$202.03
|
| Rate for Payer: HFN Commercial |
$208.84
|
| 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 |
$181.60
|
| Rate for Payer: NAPHCARE Commercial |
$76.78
|
| Rate for Payer: Preferred Network Access Commercial |
$208.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52.89
|
| Rate for Payer: Quartz Beloit One Network |
$111.23
|
| Rate for Payer: Quartz Commercial |
$147.55
|
| 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 |
$170.25
|
| Rate for Payer: WEA Trust Commercial |
$124.85
|
| Rate for Payer: Wellcare Medicare |
$51.19
|
| Rate for Payer: WMAP Medicaid |
$52.89
|
| Rate for Payer: WPS Commercial |
$168.14
|
|
|
MALT1 Interp & Report
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
2776835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$52.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.09
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.50
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$111.60
|
| Rate for Payer: The Alliance Commercial |
$744.00
|
| Rate for Payer: United Healthcare PPO |
$139.50
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
MALT1 Interp & Report
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
2776835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$171.12 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$111.60
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
MALT1 Interp & Report
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
2776835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Anthem Commercial |
$5.66
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: HFN Commercial |
$176.70
|
| 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 |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
MA Mam Digital WWHSP Diag Bilat w/ CAD
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
5144731
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$195.80 |
| Max. Negotiated Rate |
$554.67 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.00
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: HFN Commercial |
$422.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$554.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$554.67
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: The Alliance Commercial |
$222.50
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
MA Mam Digital WWHSP Diag Bilat w/ CAD
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
5144731
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.02
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: United Healthcare PPO |
$333.75
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
MA Mam Digital WWHSP Diag Bilat w/ CAD
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
5144731
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
MA Mam Digital WWHSP Diag Left w/ CAD
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
5144734
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare PPO |
$294.75
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Diag Left w/ CAD
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
5144734
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Diag Left w/ CAD
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
5144734
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$172.92 |
| Max. Negotiated Rate |
$438.07 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.80
|
| Rate for Payer: Health EOS Commercial |
$357.63
|
| Rate for Payer: HFN Commercial |
$373.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: Preferred Network Access Commercial |
$373.35
|
| Rate for Payer: Quartz Beloit One Network |
$172.92
|
| Rate for Payer: Quartz Commercial |
$224.01
|
| Rate for Payer: The Alliance Commercial |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Diag Right w/ CAD
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
5144737
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Diag Right w/ CAD
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
5144737
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$172.92 |
| Max. Negotiated Rate |
$438.07 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.80
|
| Rate for Payer: Health EOS Commercial |
$357.63
|
| Rate for Payer: HFN Commercial |
$373.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: Preferred Network Access Commercial |
$373.35
|
| Rate for Payer: Quartz Beloit One Network |
$172.92
|
| Rate for Payer: Quartz Commercial |
$224.01
|
| Rate for Payer: The Alliance Commercial |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Diag Right w/ CAD
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
5144737
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare PPO |
$294.75
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Facility
|
IP
|
$684.00
|
|
| Hospital Charge Code |
1360801
|
| Min. Negotiated Rate |
$335.16 |
| Max. Negotiated Rate |
$629.28 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$410.40
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1360834
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Professional
|
Both
|
$684.00
|
|
| Hospital Charge Code |
1360801
|
| Min. Negotiated Rate |
$300.96 |
| Max. Negotiated Rate |
$649.80 |
| Rate for Payer: Aetna Commercial |
$649.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$649.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$342.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.40
|
| Rate for Payer: Health EOS Commercial |
$622.44
|
| Rate for Payer: HFN Commercial |
$649.80
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: Preferred Network Access Commercial |
$649.80
|
| Rate for Payer: Quartz Beloit One Network |
$300.96
|
| Rate for Payer: Quartz Commercial |
$389.88
|
| Rate for Payer: The Alliance Commercial |
$342.00
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Facility
|
OP
|
$684.00
|
|
| Hospital Charge Code |
1360801
|
| Min. Negotiated Rate |
$191.52 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Aetna Managed Medicare |
$191.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$444.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$342.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$328.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$382.77
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$513.00
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$444.60
|
| Rate for Payer: Quartz Medicare Advantage |
$410.40
|
| Rate for Payer: The Alliance Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1360834
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$448.17 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.17
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Bilat
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1360834
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Bilat w/ CAD
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
5144740
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$448.17 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.17
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Bilat w/ CAD
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
5144740
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Bilat w/ CAD
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
5144740
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mam Digital WWHSP Screen Right
|
Professional
|
Both
|
$326.00
|
|
| Hospital Charge Code |
2980125
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$143.44 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.60
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: HFN Commercial |
$309.70
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: The Alliance Commercial |
$163.00
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
MA Mam Digital WWHSP Screen Right
|
Facility
|
OP
|
$326.00
|
|
| Hospital Charge Code |
2980125
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$91.28 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$91.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$211.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$163.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$156.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.43
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.50
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$195.60
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
MA Mam Digital WWHSP Screen Right
|
Facility
|
IP
|
$326.00
|
|
| Hospital Charge Code |
2980125
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
